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TiKi TaKa CK HEPATOLOGY
TiKi TaKa CK HEPATOLOGY
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. LIVER DISEASES:
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. ACUTE HEPATITIS:
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# HEPATITIS B:
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. CHRONIC disease ---> Same as acute disease but based on persistance of HbsAg > 6
months
. Best means of screening for HBV infection -> HBsAg & IgM Hbc Ab.
# HEPATITIS C:
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. HEPATITIS C DIAGNOSIS:
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. Best initial test -> Hepatitis C antibody.
. Most accurate test ->
1 - Hepatitis C PCR for RNA:determine the degree of viral activity & response to
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 &
glomerulonephritis.
. 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 already
immune.
. Both vaccinations are safe during pregnancy.
. Incidence of vertical transmission is very low 2-5 % (No need for C.S. for
pregnants).
. HCV infected mothers should NORMALLY BREAST-FEED their babies.
. VACCINATION:
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. Vaccination for both hepatitis A & B are done universally in childhood.
. No vaccine & No post-exposure prophylaxis for hepatitis C.
. N.B. PROTHROMBIN TIME IS THE SINGLE MOST IMPORTANT TEST TO ASSESS LIVER
FUNCTION !
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__
. HYPER-ESTROGENISM in Cirrhosis:
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. Due to -- clearance of Estrogen due to ++ portosystemic shunt.
. -- sex hormone binding globulin synthesis.
. Gynecomastia - testicular atrophy - spider angiomata - palmar eryhtema & -- body
hair.
. ASCITES:
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. Paracentesis if (New ascites - pain, fever & tenderness).
. HEPATIC HYDRO-THORAX:
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. Transudative pleural effusions in pts with cirrhosis,
. who have no underlying cardiac or pulmonary disease.
. Results in a RT-sided pleural effusion.
. Tx -> Salt restrictions & diuretics.
. TIPS "Trans-jugular Intra-hepatic Porto-systemic Shunt" placement in refractory
cases.
{5} HEMOCHROMATOSIS:
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. Genetic disorder -> over-absorption of copper.
. Iron deposits in various body tissues.
. Heart -> Restrictive cardiomyopathy.
. Skin -> Darkening & pigmentation.
. Joint -> Psedogout & CPPD.
. Pancreas -> Bronze Diabetes.
. Pituitary -> Panhypopituitarism.
. Genitalia -> Infertility.
. Infections -> LISTERIA, VIBRIO VULNIFICUS & YERSINIA ENTEROCOLITICA.
. Liver -> HEPATOMA & cirrhosis -> HEPATOCELLULAR CARCINOMA (Most common cause of
death).
. Dx -> Best initial test -> ++ serum iron & ferritin levels & -- TIBC.
. Dx -> Most accurate test -> Liver biopsy - MRI liver - HFe gene mutation
detection.
. Tx -> Phlebotomy.
. MANAGEMENT OF CIRRHOSIS:
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{B} . COMPENSATED:
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. U/$ surveillance for Hepatocellular carcinoma & Alpha feto-protein every 6
months.
. Esophageal endoscopy for varices surveillance.
. COAGULOPATHY MANAGEMENT:
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. Bleeding disorders occur as the liver synthesizes all clotting factors except
factor 8.
. Chief among these are Vit. K dependent factors 1972.
. Acute bleeding is best ttt with FFP FRESH FROZEN PLASMA.
. FFP contains all clotting factors.
* HYDATID DISEASE:
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. Hydatid cyst in liver.
. Caused by ECHINOCOCCUS GRANULOSUS.
. Defnitive host is DOG.
. Unilocular cystic lesions in liver, lungs, muscles & bones.
. Most pts are asymptomatic.
. Symptoms are due to compression of the surrounding tissues.
. CT -> EGG SHELL CALCIFICATION of hepatic cyst.
. Aspiration isn't indicated -> anaphylactic shock 2ry to spelling of cyst
contents.
. Tx -> Surgical resection under the cover of ALBENDAZOLE.
. LIVER MALIGNANCIES:
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* LIVER METASTASIS:
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. 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
disease.
. Mostly -> CANCER COLON -> DO COLONOSCOPY.
* HEPATIC ADENOMA:
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. 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
deposits.
. Normal liver finction tests.
. Normal AFP.
. ++ ALP & GGT.
. Complications -> Severe intra-tumor hemorrhage & malignant transformation.
. HYPER-BILIRUBINEMIA APPROACH:
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. PANCREATIC DISEASES:
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. 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 head
mass.
. ERCP -> Detect stones or strictures in the pancreatic duct system & remove them.
. 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 & medically
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.
. SEVERE PANCREATITIS:
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. 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 &
Hyperglycemia.
. 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
peritoneum,
. resulting in widespread vasodilatation, capillary leak, shock & end organ
damage.
. Dx -> CT or MRCP to detect pancreatic necrosis & extra-pancreatic inflammation.
. 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:
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. Palpable mass in the epigastrium 4 weeks after the onset of acute pancreatitis.
. Not true cysts as they lack an epithelial lining just walled by a thick fibrous
capsule
. The pseudocyst is compromized of inflammatory fluid, tissues & debris.
. The fluid contains high levels of amylase, lipase & enterokinase.
. Dx -> U/$.
. Tx -> Usually resolves spontaneously.
. Tx -> Drainage if persisting > 6 weeks or > 5 cm in diameter or becomes 2rly
infected.
. May be complicated by severe hemorrhage if eroded into a blood vessel.
. CHRONIC PANCREATITIS:
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. Due to alcohol abuse - cystic fibrosis (Children) - Autoimmune causes.
. Epigastric chronic abdominal pain.
. Intermittent pain free intervals.
. Malabsorption -> chronic diarrhea & steatorrhea.
. Weight loss & DM may occur lately.
. AMYLASE & LIPASE may be normal .. Non diagnostic.
. Plain film or CT scan -> Pancreatic calcifications. (DIAGNOSTIC).
. If x-ray & CT are -ve for calcifications -> ERCP or MRCP.
. Tx -> Pain management with frequent small meals & pancreatic enzymes supplement.
. Alcohol & smoking cessation.
. PANCREATIC CARCINOMA:
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. More in males & black race & age > 50 ys.
. Risk factors -> Chronic pancreatitis, smoking & DM.
. CIGARETTE SMOKING is the MOST CONSISTENT RISK FACTOR.
. Dull upper abdominal pain radiating to the back, weight loss & jaundice.
. Tumors located in pancreatic body or tail -> pain & weight loss.
. Tumors located in pancreatic head -> Steatorrhea, weight loss & jaundice.
. COURVOISIER's sign -> Palpable, non tender gall bladder at the Rt. costal
margin.
. VIRCHOW's NODE -> Left supra-clavicular adenopathy.
. ++ serum bilirubin & ++ ALP.
. ++ CA 19-9 levels (Serum cancer associated antigen).
. Dx -> ABDOMINAL U/$ & CT (if U$ is not diagnostic).
. Tx -> Resection of the involved tissue.
. GUESS WHAT -> ALCOHOLISM & GALL STONES ARE NOT RISK FACTORS OF PANCREATIC
CANCER !!
. EMPHYSEMATOUS CHOLECYSTITIS:
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. Due to 2ry infection of the gall bladder with gas forming bacteria e.g.
Clostridium.
. Mostly diabetic male pts aged 50 - 70 ys.
. Vascular predisposing factor e.g. obstruction or stenosis of the cystic artery.
. Right upper quadrant pain - nausea - vomiting - low grade fever.
. Crepitus in the abdominal wall adjacent to the gall bladder.
. Complications -> Gangrene & perforation.
. Dx -> Abdominal radiograph -> Air fluid level in the gall bladder.
. Dx -> Abdominal ultrasound -> Curvilinear gas shadowing in the gall bladder.
. Tx -> Immediate fluid & electrolyte resuscitation, cholycystectomy &
antibiotics.
. A-CALCULOUS CHOLECYSTITIS:
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. Acute inflammation of the gall bladder in absence of gall stones.
. Most commonly seen in hospitalized pts wit the following conditions:
. Extensive burns - severe trauma - Prolonged TPN or fasting & mechanical
ventillation.
. pathophysiology -> ischemia - biliary stasis - infection or external
compression.
. Complications -> Gangrene - perforation - emphysematous cholecystitis.
. Dx -> U/$ -> Signs of cholecystitis but No gall stones.
. CT & HIDA scan are more sensitive & specific.
. POST-OPERATIVE CHOLESTASIS:
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. Benign condition developing after a major surgery.
. Major = Hypotension - extensive blood loss into tissues - massive blood
replacement.
. Jaundice by the 2nd or 3rd post-operative day.
. Bilirubin peaks at 10 - 40 mg/dl by the 10th day.
. ALP may be elevated.
. AST & ALT NORMAL.
. POST-CHOLECYSTECTOMY $YNDROME:
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. Persistent abdominal pain, nause & dyspepsia after cholecystectomy.
. Biliary causes -> Retained common bile duct - cystic duct stone.
. Extra-biliary causes -> Pancreatitis - PUD.
. Dx -> U/$ followed by ERCP.
. POST-CHOLECYSTECTOMY PAIN:
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. Due to functional etiology e.g. SPHINCTER OF ODDI DYSFUNCTION or CBD stone.
. Normal ERCP & U/$ can rule out CBD stones.
. It is a diagnosis of exclusion.
. Tx of sphincter of Oddi dysfunction -> ERCP with sphincterotomy.
. 1 . FEBRILE NON-HEMOLYTIC:
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. Most common reaction.
. Fever & chills.
. Within 1 - 6 hours of transfusion.
. Caused by cytokine accumulation during blood storage.
. 2 . ACUTE HEMOLYTIC:
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. Fever, flank pain, hemoglobinuria, renal failure & DIC.
. Within 1st hour of transfusion.
. +ve direct Coomb's test & pink plasma.
. Caused by ABO INCOMPATIBILITY.
. 3 . DELAYED HEMOLYTIC:
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. Mild fever & hemolytic anemia.
. Within 2 - 10 days of transfuion.
. +ve direct Coomb's test & +ve new antibody screen.
. caused by ANAMNESTIC ANTIBODY RESPONSE.
. 4 . ANAPHYLACTIC:
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. Rapid onset of shock, angioedema, urticaria & respiratory distress.
. Within a few seconds to minutes of the transfusion.
. Caused by RECEPIENT anti-Ig"A" Abs.
. 5 . URTICARIAL = ALLERGIC:
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. Urticaria - flushing - angioedema & pruritis.
. Within 2 - 3 hours of transfusion.
. Caused by RECEPIENT Ig"E" Abs & mast cell activation.
. N.B. Individuals who received blood transfusions before 1992 sh'd be screened for
HCV.
. N.B. Individuals who received blood transfusions before 1986 sh'd be screened for
HBV.