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Tiki Taka CK Hepatology
Tiki Taka CK Hepatology
______________________
. LIVER DISEASES:
_________________
_________________
. ACUTE HEPATITIS:
__________________
__________________
. Jaundice - fatigue - weight loss - drak urine (bilirubin in urine).
. Hepatitis B & C present with serum sickness phenomena (arthralgia - urticaria
- fever).
. HBV is associated with polyarteritis nodosa (PAN) !
. HCV is associated with Cryoglobulinema.
. HEV is most severe in PREGNANT WOMEN .. It can be fatal.
. Dx -> ++ CONJUGATED (DIRECT) BILIRUBIN.
. Dx -> ++ ALLLLLLLLT -> VIRALLLLLLLLL hepatitis.
. Dx -> ++ ASSSSSSSST -> DRUGSSSSSSSSS hepatitis.
. Dx -> AST:ALT = 2:1 -> ALCOHOLIC hepatitis.
. Dx -> Most accurate test -> Serology (IgG & IgM).
. N.B. EVALUATION OF LIVER DAMAGE:
___________________________________
-> ACUTE HEPATITIS -> Liver function tests & Viral serology.
-> CHRONIC HEPATITIS -> Liver biopsy.
# HEPATITIS B:
_______________
. HEPATITIS B DIAGNOSIS -> SEROLOGY:
____________________________________
. The 1st test to become ABNORMAL in ACUTE HB infection is SURFACE ANTIGEN (HBs
Ag).
. ++ ALT, e-antigen & symptoms all occur after the appearance of HBsAg.
...................... Surface Ag ........ e-Ag ......... Core Ab .......... Su
rface Ab
. ACUTE disease ----->
(--)
++
........ ++ .........
++
..........
--
........ -- .........
. VACCINATED -------->
(++)
--
........ -- ..........
--
(++) ..........
--
...........
. CHRONIC disease ---> Same as acute disease but based on persistance of HbsAg
> 6 months
. Anti HBc Ig "G" Ab -> Denotes CHRONICITY !
. Best means of screening for HBV infection -> HBsAg & IgM Hbc Ab.
. N.B. ACUTE VIRAL REPLICATION indicators:
__________________________________________
. Hepatitis B DNA plymerase = e-Antigen = Hepatitis B PCR for DNA.
. CHRONIC HEPATITIS B TREATMENT:
________________________________
. Chronicity = More than 6 months with +ve serology.
. Tx -> Anti-viral therapy -> LAMIVUDINE + INTERFERON.
# HEPATITIS C:
______________
. HEPATITIS C DIAGNOSIS:
________________________
. Best initial test -> Hepatitis C antibody.
. Most accurate test ->
1 - Hepatitis C PCR for RNA:determine the degree of viral activity & response t
o therapy.
2 - Liver biopsy: determine the seriousness of the disease i.e. extent of liver
damage.
. Chronic HCV classically presents with waxing & waning transaminases levels &
few syms.
. Pts may complain of arthralgias or myalgias.
. Extra-hepatic sequlae: Cryoglobulinemia - porphyria cutanea tarda & glomerulo
nephritis.
. CHRONIC HEPATITIS C TREATMENT:
________________________________
. All chronic hepatitis C pts with ++ ALT, detectable HCV RNA & histologic evid
ence.
. Tx -> Anti-viral therapy -> RIBAVIRIN + INTERFERON.
. Chronic HCV pts with persistently NORMAL liver enzymes & MINIMAL histological
findings,
. NO NEED TO BE TTT WITH INTERFERON OR ANTI-VIRAL DRUGS.
. JUST follow up with yearly liver function tests.
. All chronic HCV pts sh'd receive vaccinations to Hepatitis A & B if not alrea
dy immune.
. Both vaccinations are safe during pregnancy.
. Incidence of vertical transmission is very low 2-5 % (No need for C.S. for pr
egnants).
. HCV infected mothers should NORMALLY BREAST-FEED their babies.
. SE of Ribavirin -> Anemia.
____________________________
. SE of Interferon -> Arthralgia - myalgia - flu-like $ - thrombocytopenia - dep
ression.
________________________________________________________________________________
________
. VACCINATION:
______________
. Vaccination for both hepatitis A & B are done universally in childhood.
. No vaccine & No post-exposure prophylaxis for hepatitis C.
. INDICATIONS for HEPATITIS A & B:
___________________________________
1 - CHRONIC LIVER DISEASE -> Cirrhosis.
2 - HOUSE HOLD CONTACTS -> of pts with hepatitis A & B.
3 - HOMOSEXUAL MEN !
4 - Chronic recepients of blood products.
5 - Injection drug users.
. SPECIFIC INDICATIONs FOR HEPATITIS A & B VACCINE:
___________________________________________________
. A -> TRAVELERS.
. B -> Health care workers & patients on dialysis.
. POST-EXPOSURE PROPHYLAXIS FOR HEPATITIS B:
____________________________________________
. Health care worker got stucked with a needle contaminated with blood from HBV
pt.
. A child born to a mother with chronic hepatitis B.
. GIVE -> HEPATITIS B IMMUNOGLOBULIN + HEPATITIS B VACCINE.
. If the person had already been vaccinated,
. Check the levels of protective HBsAb (surface antibodies).
. If protective antibodies are ALREADY present -> No further ttt.
. FULMINANT HEPATIC FAILURE:
____________________________
. Hepatic encephalopathy developing within 8 weeks of the onset of acute liver
failure.
. More common in pts using heavily using acet5aminophens & alcohols.
. Mostly their is co-infection of hepatitis B & D.
. Markedly ++ ALT, ++ PT & coagulopathy.
. HIGH PRIORITY CANDIDATES FOR LIVER TRANSPLANTATION. (The only effective ttt!)
.
. N.B. PROTHROMBIN TIME IS THE SINGLE MOST IMPORTANT TEST TO ASSESS LIVER FUNCTI
ON !
________________________________________________________________________________
_____
. ASYMPTOMATIC ++ OF LIVER FUCTION TESTS (AST & ALT) APPROACH:
______________________________________________________________
.1. Ask for H/O of drug or alcohol intake, travel outside USA, blood transfusio
n or sex.
.2. Drugs (NSAIDs - Antibiotics - Anti-epileptic - Anti-tuberculous).
.3. Repeat the tests again to confirm the elevations !
.4. If elevation persists > 6 months -> Chronic.
.5. So .. test for HBV & HCV, Hemochromatosis & fatty liver.
. INH (ISONIAZID) INDUCED HEPATITIS:
____________________________________
. INH may induce sub-clinical hepatitis.
. Mild elevation of ALT & AST (< 100 IU/L).
. The hepatic injury is typicall self-limited.
. No ttt is needed .. The condition will resolve spontaneously.
. Tx -> prednisone.
{7} NON-ALCOHOLIC STEATOHEPATITIS (NASH):
__________________________________________
. Associated with obesity - DM - Hyperlipidemia.
. Hepatomegaly.
. Patho-physiology -> INSULIN RESISTANCE.
. Dx -> Best initial test -> ALT > AST.
. Dx-> Most accurate test -> Liver biopsy (Fatty infiltration).
. The liver biopsy looks alike Alcoholic liver disease !!
. Tx -> No specific therapy.
. Control the underlying cause e.g. weight loss - DM control.
{8} ALPHA - 1 ANTI-TRYPSIN DEFECIENCY:
_______________________________________
. PAN-ACINAR EMPHYSEMA + CIRRHOSIS.
. Co-existing lung involvement.
. Family H/O of cirrhosis.
{9} CARDIAC CIRRHOSIS:
_______________________
. Co-existing right-sided heart failure.
. MANAGEMENT OF CIRRHOSIS:
__________________________
__________________________
{A} . PERIODIC SURVEILLANCE OF Liver Function Tests (INR - Albumin - Bilirubin)
:
________________________________________________________________________________
_
{B} . COMPENSATED:
___________________
. U/$ surveillance for Hepatocellular carcinoma & Alpha feto-protein every 6 mo
nths.
. Esophageal endoscopy for varices surveillance.
{C} . DECOMPENSATED -> ASSESS COMPLICATIONS:
_____________________________________________
. VARICEAL HEMORRHAGE -> Start non selective BB - Repeat esophageal endoscopy e
very year.
. Ascites -> Dietary sodium restriction, diuretics, paracentesis & Alcohol abst
inence.
. Hepatic encephalopathy -> identify the cause (infection - GIT bleeding) & Lac
tulose.
. VARICEAL BLEEDING MANAGEMENT:
_______________________________
. The 1st step in ttt of ACUTE VARICEAL BLEADING is to establish vascular acces
s,
. with TWO LARGE BORE INTRAVENOUS NEEDLES OR CENTRAL LINE.
. Then .. Control the bleeding itself !
. In 50 % of cases, bleeding ceases on its own.
. Other 50 % -> Vasoconstrictors (Terlipressin) = Synthetic analogue of vasopre
ssin.
. HEPATIC ENCEPHALOPATHY MANAGEMENT:
____________________________________
_____________________
_____________________
* LIVER METASTASIS:
____________________
. 20 times more common than HCC.
. Tumors of GIT, lung & breast are the most common culprits.
. May be asymptomatic & discovered accidentally.
. If symptomatic: Hepatomegaly, jaundice, cholestasis & ++ alkaline phosphatase
(ALP).
. NORMAL ALPHA FETO-PROTEIN (AFP).
. Dx -> CT -> Multiple hepatic nodules of varying sizes.
. Confirmed by liver biopsy.
. Multiple liver masses are much more likely to be the result of a metastatic d
isease.
. Mostly -> CANCER COLON -> DO COLONOSCOPY.
* HEPATOCELLULAR CARCINOMA (HCC):
__________________________________
. Less common than metastasis.
. ++++ ALPHA FETOPROTEIN.
. CT -> SOLITARY large lesion.
* HEPATIC ADENOMA:
___________________
. Benign rare liver tumor.
. Young & middle aged women with H/O of OCP intake.
. Palpable liver mass.
. Liver biopsy -> Mildly atypical hepatocytes containing glycogen & lipid depos
its.
. Normal liver finction tests.
. Normal AFP.
. ++ ALP & GGT.
. Complications -> Severe intra-tumor hemorrhage & malignant transformation.
. ALCOHOLIC LIVER DISEASES:
___________________________
. Females are more susceptible than males to alcoholic liver diseases !!
. Alcoholic fatty liver is reversible condition.
. AST:ALT -> 2:1.
. 80 % of alcoholics will develop fatty liver.
. 20 % of alcoholics will develop hepatitis.
. 50 % of alcoholics will develop cirrhosis.
.
.
.
.
. PANCREATIC DISEASES:
______________________
______________________
. ACUTE PANCREATITIS:
_____________________
. Severe mid-epigastric abdominal pain radiating to the back.
. Vomiting without blood - Anorexia - Tendrness in the epigastric area.
. Main causes are ALCOHOLISM & GALL STONES.
. Other causes -> Hypertiglyceridemia - trauma - infection - iatrogenic ERCP.
. Dx -> Best initial test ->
* ++ Amylase & lipase (most sensitive & specific) -> ++ Amylase/lipase
3 times.
* ABDOMINAL ULTRA$OUND -> Diffusely enlarged hypoechoic pancreas.
. Dx -> Most accurate test -> Abdominal CT scan:
* Detect dilated common bile ducts.
* Comment on intra-hepatic ducts.
. Dx -> N.B. -> ++ ALT > 150 & ++ ALP -> Biliary pancreatitis.
. MRCP -> Detects causes of biliary & pancreatic duct obstruction not found on
CT scan.
. ERCP -> If there is dilatation of the common bile duct without a pancreatic h
ead mass.
. ERCP -> Detect stones or strictures in the pancreatic duct system & remove th
em.
. Tx -> NPO - Bowel rest - Hydration - pain medications.
. N.B. (1):
____________
. If the cause of acute pancreatitis was gall stones not alcoholism,
. Once the pt. recovers with normalization of the pancreatic enzymes & medicall
y stable,
. CLOLECYSTECTOMY IS A MUST !
. N.B. (2):
____________
. Acute pancreatitis in pts without gall stones or a H/O of alcohol use.
. HYPER-TRIGLYCERIDEMIA > 1000 mg/dl -> Acute pancreatitis.
. Eruptive xanthoma on exam.
. Dx -> FASTING LIPID PROFILE.
. COMPLICATIONS OF SEVERE PANCREATITIS:
________________________________________
. 1 . Pseudocyst.
. 2 . Peri-pancreatic fluid collection.
. 3 . Necrotizing pancreatitis.
. 4 . ARD$.
. 5 . ARF.
. 6 . GIT bleeding.
. SEVERE PANCREATITIS:
______________________
. Pancreatitis with failure of at least 1 organ !
. Predisposing factors: Age > 75 ys, Alcoholism & obesity.
. CULLEN SIGN -> Peri-umbilical bluish coloration indicating hemoperitoneum.
. GREY-TURNER SIGN -> Reddish brown coloration around flanks = retroperitoneal
bleeding.
. ++ CRP > 150 mg/dl in the 1st 48 hs.
. ++ Urea & creatinine in the 1st 48 hs.
. Severe cases -> (-- BP, -- Ca, -- O2, -- pH) & (++ WBCs, ++ glucose).
. Hypotension, Hypoxia, Metabolic Acidosis, Hypocalcemia, Leukocytosis & Hyperg
lycemia.
. Hypocalcemia due to fat malabsorption.
. severe pancreatitis may lead to release of activated pancreatic enzymes,
. that enter the vascular system & ++ the vascular permeability,
. so, large volumes of fluid migrate from the vascular system to surrounding pe
ritoneum,
. resulting in widespread vasodilatation, capillary leak, shock & end organ dam
age.
. Dx -> CT or MRCP to detect pancreatic necrosis & extra-pancreatic inflammatio
n.
. Tx -> Supportive with several liters of IV fluids.
. NECROTIZING PANCREATITIS:
___________________________
. Dx -> CT.
. Tx -> If > 30 % necrosis -> IV Antibiotics (Imipenem) & CT guided biopsy.
. If the biopsy showed infected necrotic pancreatitis -> SURGICAL DEBRIDEMENT.
. Surgical debridement is done to prevent ARD$ & death.
. PANCREATIC PSEUDOCYST:
________________________
. Palpable mass in the epigastrium 4 weeks after the onset of acute pancreatiti
s.
. Not true cysts as they lack an epithelial lining just walled by a thick fibro
us capsule
. The pseudocyst is compromized of inflammatory fluid, tissues & debris.
. The fluid contains high levels of amylase, lipase & enterokinase.
. Dx -> U/$.
. Tx -> Usually resolves spontaneously.
. Tx -> Drainage if persisting > 6 weeks or > 5 cm in diameter or becomes 2rly
infected.
. May be complicated by severe hemorrhage if eroded into a blood vessel.
. DRUG INDUCED PANCREATITIS:
____________________________
. Mild & usually resolves with supportive care !
. CT scan is diagnostic.
. Pt on diuretics -> Furosemide & thiazides.
. Pt on antibiotics -> Metronidazole & tetracyclines.
. Pt with IBD -> Sulfasalazine.
. Pt on immunosuppressives -> Azathioporine.
. Pt with seizures or bipolar disorder -> Valproic acid.
. Pt with AIDS -> Didanosine & pentamidine.
. CHRONIC PANCREATITIS:
_______________________
. Due to alcohol abuse - cystic fibrosis (Children) - Autoimmune causes.
. Epigastric chronic abdominal pain.
. Intermittent pain free intervals.
. Malabsorption -> chronic diarrhea & steatorrhea.
. Weight loss & DM may occur lately.
. AMYLASE & LIPASE may be normal .. Non diagnostic.
. Plain film or CT scan -> Pancreatic calcifications. (DIAGNOSTIC).
. If x-ray & CT are -ve for calcifications -> ERCP or MRCP.
. Tx -> Pain management with frequent small meals & pancreatic enzymes suppleme
nt.
. Alcohol & smoking cessation.
. PANCREATIC CARCINOMA:
_______________________
. More in males & black race & age > 50 ys.
. Risk factors -> Chronic pancreatitis, smoking & DM.
. CIGARETTE SMOKING is the MOST CONSISTENT RISK FACTOR.
. Dull upper abdominal pain radiating to the back, weight loss & jaundice.
. Tumors located in pancreatic body or tail -> pain & weight loss.
. Tumors located in pancreatic head -> Steatorrhea, weight loss & jaundice.
. COURVOISIER's sign -> Palpable, non tender gall bladder at the Rt. costal mar
gin.
. VIRCHOW's NODE -> Left supra-clavicular adenopathy.
. ++ serum bilirubin & ++ ALP.
. ++ CA 19-9 levels (Serum cancer associated antigen).
. Dx -> ABDOMINAL U/$ & CT (if U$ is not diagnostic).
. Tx -> Resection of the involved tissue.
. GUESS WHAT -> ALCOHOLISM & GALL STONES ARE NOT RISK FACTORS OF PANCREATIC CA
NCER !!
. PANCREATIC CANCER VS CHRONIC PANCREATITIS:
____________________________________________
. Both may present with epigastric pain.
. (Old age, jaundice & weight loss) favors malignancy.
. Mild elevation of amylase & lipase are consistent with chronic pancreatitis.
. ++ serum Bilirubin & ALP = compression of the intra-pancreatic bile duct = Ma
lignancy.
. Best initial test -> ABDOMINAL U/$ -> DILATED BILE DUCTS & MASS IN HEAD OF PA
NCREAS.
. CT abdomen is more specific than U/$.
. If CT failed -> i.e. No mass lesion -> Do ERCP.
. If ERCP failed -> due to pancreatic duct obstruction -> Do MRI.
. GALL BLADDER DISEASES:
________________________
________________________
. GALL STONE DISEASE = CHOLELITHIASIS:
______________________________________
. Types of gall stones (Cholesterol - Pigment "Ca bilirubinate" - Mixed).
. Msot common is Cholesterol stone & least common is pigment "Ca bilirubinate".
. 80 % of stones are RADIO-OPAQUE.
. FAT - FERTILE - FEMALE - FORTY - FILTHY !
. Native American - DM - Obesity - OCP & pregnancy are common predisposing fact
ors.
. Bloating & dyspepsia after eating fatty foods.
. RUQ abdominal pain.
. Dx -> Abdominal U/$.
. Tx -> LAPAROSCOPIC CHOLECYSTECTOMY.
. If refused the operation -> Give ursodeoxycholic acid & advise to avoid fatty
foods.
. Asymptomatic gall stones should NOT be treated.
. Symptomatic gall stones -> LAPAROSCOPIC CHOLECYSTECTOMY.
. ACUTE CHOLECYSTITIS = ACUTE GALL BLADDER INFLAMMATION:
________________________________________________________
. CHARCOT's TRIAD -> Fever + severe jaundice + RUQ abd pain radiating to the Rt
shoulder.
. REYNOLD's PENTAD -> + Confusion + Hypotension -> (Suppurative cholangitis).
. Most commonly due to obstruction of the common bile duct by stone.
. The original incinting event is a gall stone obstructing the CYSTIC DUCT (Not
CBD) !!!
. MURPHY's SIGN -> pain on palpation of area of gall bladder fossa on deep insp
iration.
. ++ WBCs & ++ ALP (cholestasis & obstruction).
. Dx -> U/$.
. Tx -> Supportive care & broad spectrum antibiotics.
. Most pts recover completely, but despite adequate fluids & antibiotics,
. Some pts continue to have persistent abd. pain, hypotension, high fever & con
fusion.
. This is an indication of URGENT BILIARY DECOMPRESSION by ERCP.
. ERCP -> Sphincterotomy & stone removal or stent insertion.
. Lap. cholecystectomy won't accomplish drainage of the biliary tree "main conc
ern" !
. Pt will undergo cholecystectomy later on but drainage of the biliary tree is
more imp.
. EMPHYSEMATOUS CHOLECYSTITIS:
______________________________
. Due to 2ry infection of the gall bladder with gas forming bacteria e.g. Clost
ridium.
. Mostly diabetic male pts aged 50 - 70 ys.
. Vascular predisposing factor e.g. obstruction or stenosis of the cystic arter
y.
. Right upper quadrant pain - nausea - vomiting - low grade fever.
. It is a diagnosis of exclusion.
. Tx of sphincter of Oddi dysfunction -> ERCP with sphincterotomy.
. VANISHING BILE DUCT $YNDROME:
_______________________________
. progressive destruction of the intra-hepatic bile ducts.
. Histological hallmark -> Ductopenia.
. Primary bilary cirrhosis is the most common cause of ductopenia in adults.
. Primary scerosing cholangitis is not related to ductopenia.
. DIFFERENT DIAGNOSTIC TOOLS USED FOR GALL BLADDER DISEASES:
____________________________________________________________
{1} * ABDOMINAL ULTRA$OUND:
____________________________
. Best initial investigation of gall bladder diseases.
{2} * ERCP = ENDOSCOPIC RETRO-GRADE CHOLANGIO-PANCREATOGRAPHY:
_______________________________________________________________
. Best diagnostic & therapeutic tool in evaluation of chronic pancreatitis & CB
D disease.
. Most accurate test of detecting causes, location & extent of bile duct obstru
ction.
. Therapeutic: Stone extraction, sphincterotomy, balloon dilatation & stent pla
cement.
. TTT of choice in case of sphincter of Oddi dysfunction.
{3} * ABDOMINAL RADIOGRAPHS:
_____________________________
. Neither sensitive nor specific.
. > 80 % of gall stones are radio-lucent so can't be visualized.
{4} * HIDA SCAN:
_________________
. Use technitium labelled compounds to demonstarate bile duct obstruction & GB
diseases.
. It is superior to U/$ in confirming suspected acute cholecystitis (Acalculus
type).
{5} * PTC = PER-CUTANEOUS TRANS-HEPATIC CHOLANGIOGRAPHY:
_________________________________________________________
. study the intra & extra hepatic biliary tree.