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. LIVER DISEASES:
. ACUTE HEPATITIS:
. Jaundice - fatigue - weight loss - dark urine (bilirubin in urine).
. Hepatitis B & C present with serum sickness phenomena (arthralgia - urticaria - fever).
# HEPATITIS B:
. HEPATITIS B DIAGNOSIS -> SEROLOGY:
. The 1st test to become ABNORMAL in ACUTE HB infection is SURFACE ANTIGEN (HBsAg).
. ++ ALT, e-antigen & symptoms all occur after the appearance of HBsAg.
--
ACUTE disease ++ ++ ++
WINDOW PHASE
(RECOVERING)
-- --
++ --
VACCINATED -- -- --
++
HEALED
RECOVERED
-- -- ++
++
. 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:
. HEPATITIS C DIAGNOSIS:
. Best initial test -> Hepatitis C antibody.
. Most accurate test ->
1 - 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 sequelae: 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.
. SE of Ribavirin -> Anemia.
. SE of Interferon -> Arthralgia - myalgia - flu-like $ - thrombocytopenia - depression.
. VACCINATION:
. 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 !
. HYPER-ESTROGENISM in Cirrhosis:
. Due to -- clearance of Estrogen due to ++ portosystemic shunt.
. -- sex hormone binding globulin synthesis.
. Gynecomastia - testicular atrophy - spider angiomata - palmar erythema & -- body hair
. ASCITES:
. Paracentesis if (New ascites - pain, fever & tenderness).
{5} HEMOCHROMATOSIS:
. 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:
{A} . PERIODIC SURVEILLANCE OF Liver Function Tests (INR - Albumin - Bilirubin).
{B} . COMPENSATED:
. U/$ surveillance for Hepatocellular carcinoma & Alpha feto-protein every 6 months.
. Esophageal endoscopy for varices surveillance.
* HYDATID DISEASE:
. Hydatid cyst in liver.
. Caused by ECHINOCOCCUS GRANULOSUS.
. Definitive host is DOG.
. Uni-locular 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.
* 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 deposits.
. Normal liver function tests.
. Normal AFP.
. ++ ALP & GGT.
. Complications -> Severe intra-tumor hemorrhage & malignant transformation.
. HYPER-BILIRUBINEMIA APPROACH:
{A} MAINLY UN-CONJUGATED:
. Over-production (hemolysis).
. Reduced up-take (drugs & porto-systemic shunt).
. Conjugation defect (Gilbert's $).
. PANCREATIC DISEASES:
. ACUTE PANCREATITIS:
. Severe mid-epigastric abdominal pain radiating to the back.
. Vomiting without blood - Anorexia - Tenderness in the epigastric area.
. Main causes are ALCOHOLISM & GALL STONES.
. Other causes -> Hypertriglyceridemia - trauma - infection - iatrogenic ERCP.
. Dx -> Best initial test ->
* ++ Amylase & lipase (most sensitive & specific) -> ++ Amylase/lipase 3 times.
* ABDOMINAL ULTRA$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 ..
CHOLECYSTECTOMY 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$.
. 5 . ARF.
. 6 . GIT bleeding.
. SEVERE PANCREATITIS:
. Pancreatitis with failure of at least 1 organ !
. Predisposing factors: Age > 75 ys, Alcoholism & obesity.
. CULLEN SIGN -> Peri-umbilical bluish coloration indicating hemoperitoneum.
. GREY-TURNER SIGN -> Reddish brown color around flanks = retroperitoneal bleeding.
. ++ CRP > 150 mg/dl in the 1st 48 hs.
. ++ Urea & creatinine in the 1st 48 hs.
. Severe cases -> (-- BP, -- Ca, -- O2, -- pH) & (++ WBCs, ++ glucose).
. Hypotension, Hypoxia, Metabolic Acidosis, Hypocalcemia, ++WBCs & Hyperglycemia.
. Hypocalcemia due to fat malabsorption.
. severe pancreatitis may lead to release of activated pancreatic enzymes,
. that enter the vascular system & ++ the vascular permeability,
. so, large volumes of fluid migrate from the vascular system to peritoneum,
. resulting in widespread vasodilatation, capillary leak, shock & end organ damage.
. Dx -> CT or MRCP to detect pancreatic necrosis & extra-pancreatic inflammation.
. Tx -> Supportive with several liters of IV fluids.
. NECROTIZING PANCREATITIS:
. Dx -> CT.
. Tx -> If > 30 % necrosis -> IV Antibiotics (Imipenem) & CT guided biopsy.
. If the biopsy showed infected necrotic pancreatitis -> SURGICAL DEBRIDEMENT.
. Surgical debridement is done to prevent ARD$ & death.
. PANCREATIC PSEUDOCYST:
. 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 compromised of inflammatory fluid, tissues & debris.
. The fluid contains high levels of amylase, lipase & enterokinase.
. Dx -> U/$.
. Tx -> Usually resolves spontaneously.
. Tx -> Drainage if persisting > 6 weeks or > 5 cm in diameter or becomes 2rly infected.
. May be complicated by severe hemorrhage if eroded into a blood vessel.
. CHRONIC PANCREATITIS:
. Due to alcohol abuse - cystic fibrosis (Children) - Autoimmune causes.
. Epigastric chronic abdominal pain.
. Intermittent pain free intervals.
. Malabsorption -> chronic diarrhea & steatorrhea.
. Weight loss & DM may occur lately.
. AMYLASE & LIPASE may be normal .. Non diagnostic.
. Plain film or CT scan -> Pancreatic calcifications. (DIAGNOSTIC).
. If x-ray & CT are -ve for calcifications -> ERCP or MRCP.
. Tx -> Pain management with frequent small meals & pancreatic enzymes supplement.
. Alcohol & smoking cessation.
. PANCREATIC CARCINOMA:
. More in males & black race & age > 50 ys.
. Risk factors -> Chronic pancreatitis, smoking & DM.
. CIGARETTE SMOKING is the MOST CONSISTENT RISK FACTOR.
. Dull upper abdominal pain radiating to the back, weight loss & jaundice.
. Tumors located in pancreatic body or tail -> pain & weight loss.
. Tumors located in pancreatic head -> Steatorrhea, weight loss & jaundice.
. COURVOISIER's sign -> Palpable, non tender gall bladder at the Rt. costal margin.
. VIRCHOW's NODE -> Left supra-clavicular adenopathy.
. ++ serum bilirubin & ++ ALP.
. ++ CA 19-9 levels (Serum cancer associated antigen).
. Dx -> ABDOMINAL U/$ & 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:
. 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, cholecystectomy & antibiotics.
. A-CALCULOUS CHOLECYSTITIS:
. 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 ventilation.
. 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:
. 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 $YNDROME:
. Persistent abdominal pain, nause & dyspepsia after cholecystectomy.
. Biliary causes -> Retained common bile duct - cystic duct stone.
. Extra-biliary causes -> Pancreatitis - PUD.
. Dx -> U/$ followed by ERCP.
. POST-CHOLECYSTECTOMY PAIN:
. 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.
. 2 . ACUTE HEMOLYTIC:
. 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:
. 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:
. 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:
. 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.