HEPATOLOGY TiKi TaKa

______________________
. 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
(HBsAg).
. ++ ALT, e-antigen & symptoms all occur after the appearance of HBsAg.
...................... Surface Ag ........ e-Ag ......... Core Ab .......... Surface Ab
. ACUTE disease ----->
. WINDOW PHASE ------>

++
--

........ ++ .........

++ ..........

........ -- ......... (++) ..........

(--)
--

(RECOVERING)
. VACCINATED -------->

--

. HEALED RECOVERED -->

........ -- .......... -- ........... (++)

--

........ -- .......... (++) ........... (++)

. 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 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 HEPATITIS C TREATMENT:
________________________________
. All chronic hepatitis C pts with ++ ALT, detectable HCV RNA & histologic evidence.
. 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 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.
. 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
FUNCTION !
_____________________________________________________________________________________
. ASYMPTOMATIC ++ OF LIVER FUCTION TESTS (AST & ALT) APPROACH:
______________________________________________________________
.1. Ask for H/O of drug or alcohol intake, travel outside USA, blood transfusion 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.
. CHRONIC HEPATITIS -> CIRRHOSIS:
_________________________________
_________________________________
. CHRONIC ALCOHOL ABUSE & VIRAL HEPATITIS ARE THE MOST COMMON CAUSES.
. GENERAL FEATURES OF CIRRHOSIS:
_________________________________
1 - Edema -> from low oncotic pressure -> Tx: Spironolactone & diuretics.
2 - Gynecomastia.
3 - Palamar erythema.
4 - Splenomegaly.
5 - Thrombocytopenia (Caused by splenic sequestration).
6 - Encephalopathy (Tx: lactulose).
7 - Ascites (Tx: spironolactone).
8 - Esophageal varices (Tx: propranolol will prevent bleeding - Banding if rebleed).
. HYPER-ESTROGENISM in Cirrhosis:
_________________________________
. Due to -- clearance of Estrogen due to ++ portosystemic shunt.
. -- sex hormone binding globulin synthesis.
. Gynecomastia - testicular atrophy - spider angiomata - palmar eryhtema & -- body
hair.
. ASCITES:
___________
. Paracentesis if (New ascites - pain, fever & tenderness).

. SERUM TO ASCITES ALBUMIN GRADIENT (SAAG):

___________________________________________
-> < 1.1 -> EXUDATE -> NO portal hypertension.
-> > 1.1 -> TRANSUDATE -> PORTAL HYPERTENSION (++ Capillary hydrostatic
pressure).
. SPONTANEOUS BACTERIAL PERITONITIS:
____________________________________
-> Pt with cirrhosis & ascites presenting with low grade fever, abd. pain & or
confusion.
-> Dx -> Best initial test -> Cell count > 250 neutrophils.
-> Dx -> Most accurate -> Fluid culture.
-> Tx -> CEFOTAXIME.
-> Prevent recurrence -> TMP-SMX.
. HEPATIC HYDRO-THORAX:
_______________________
. 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.
. CHRONIC LIVER DISEASES (CAUSES OF CIRRHOSIS):
_______________________________________________
{1} ALCOHOLIC CIRRHOSIS:
_________________________
. Diagnosis of exclusion !!
. H/O of long-standing alcohol abuse.
{2} PRIMARY BILIARY CIRRHOSIS (PBC):
_____________________________________
. Not related to IBD !!
. Middle-aged woman.
. ITCHING !
. XANTHELASMA (Cholesterol deposits).
. H/O of other autoimmune diseases.
. Best initial test -> ++ ALP Alkaline phosphatase with NORMAL BILIRUBIN level.
. ++ IgM.
. Most accurate test -> Anti-mitochondrial antibody (AMA) & Liver biopsy.
. Tx -> Ursodeoxycholic acid.
{3} PRIMARY SCLEROSING CHOLANGITIS (PSC):
__________________________________________
. Inflammatory bowel disease (IBD) accounts for 80% of causes (UC > CD).
. ITCHING !
. Best initial test -> ++ ALP Alkaline phosphatase with ++ BILIRUBIN level.
. Most accurate test -> ERCP -> BEADING of the biliary system.

. +ve ASMA (Anti-smooth muscle antibody).

. +ve ANCA.
. Tx -> Ursodeoxycholic acid.
{4} WILSON's DISEASE = HEPATO-LENTICULAR DEGENERATION:
_______________________________________________________
. -- Ceruloplasmin -> ++ Copper.
. Abnormal Copper deposition in liver, basal ganglia & cornea.
. Young pt < 30 ys.
. Cirrhosis + Choreiform movement disorder + Neuropsychiatric abnormalities.
. May present with hemolysis.
. Best initial test -> Slit lamp (Keiser Fleischer rings) & -- Ceruloplasmin level <
20mg
. Most accurate test -> Liver biopsy -> Copper level > 250 mcg/gram.
. Tx -> Penicillamine.
{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.
{6} AUTO-IMMUNE HEPATITIS:
___________________________
. Young woman with other auto-immune diseases (Coomb's +ve AIHA, thyroiditis &
ITP).
. Best initial test -> ANA & ASMA & Liver/kidney microsomal antibody.
. Serum protein electrophoresis (SPEP) -> Hyper-gamma globulinemia.
. Most accurate test -> Liver biopsy.
. 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
months.
. Esophageal endoscopy for varices surveillance.
{C} . DECOMPENSATED -> ASSESS COMPLICATIONS:
_____________________________________________
. VARICEAL HEMORRHAGE -> Start non selective BB - Repeat esophageal
endoscopy every year.
. Ascites -> Dietary sodium restriction, diuretics, paracentesis & Alcohol abstinence.
. Hepatic encephalopathy -> identify the cause (infection - GIT bleeding) &
Lactulose.
. VARICEAL BLEEDING MANAGEMENT:
_______________________________
. The 1st step in ttt of ACUTE VARICEAL BLEADING is to establish vascular access,
. 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 vasopressin.
. HEPATIC ENCEPHALOPATHY MANAGEMENT:
____________________________________
. Decline in neurologic function due to hepatic damage.
. Due to ++ AMMONIA level in circulation & production of false neurotransmitters.
. TTT principles -> Correction of ppt factor & lowering of blood ammonia
concentration.

. PPT factors -> hypovolemia - GIT bleeding - infection - hypoxia - hypoglycemia & -K.
. Lower blood ammonia using DISACCHARIDE (LACTULOSE) -> Ammonia trap.
. Add NEOMYCIN -> Destroy ammonia producing colonic bacteria (OTO & NEPHROTOXIC).
. Lower protein in diet (BUT .. NOT PTN FREE DIET xxxx) !
. COAGULOPATHY MANAGEMENT:
__________________________
. 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.
* AMEBIC LIVER ABSCESS:
_______________________
. Amebiasis is aprotozoal disease caused by ENTAMOEBA HISTOLYTICA.
. H/O of travel to endemic area e.g. MEXICO.
. Followed by dysentery, RUQ. pain & diarrhea.
. The primary infection is the colon leading to bloody diarrhea,
. Ameba may be transported to the liver by portal circulation -> Amebic liver
abscess.
. Fever up to 39.5 c.
. ++ WBCs & ++ ALP.
. Generally SINGLE & located in the RT lobe.
. Dx -> Stool exam. -> trophozites.
. CT -> Liver mass (cystic not solid lesion).
. Needle aspiration is not performed due to risk of bleeding & peritonitis.
. The fluid inside is called "anchovy paste" - STERILE & odourless unless 2ry
infected.
. Tx -> ORAL METRONIDAZOLE. (NOT SURGICAL RESECTION!).
* HYDATID DISEASE:
___________________
. 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.
* ISCHEMIC HEPATIC INJURY = SHOCK LIVER:
_________________________________________
. Accompanies severe hypotension or shock.
. Rapid massive +++ in transaminases.

. Minimal ++ in bilirubin & ALP.

. Once the predisposing factor disappears, the transaminases return to normal.
. LIVER MALIGNANCIES:
_____________________
_____________________
* 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
disease.
. 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 deposits.
. 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.
. H/O of heavy alcohol use.

. Hepatomegaly (Liver span > 12 cm in MCL).

. ++ MCV.
. ++ AST : ALT = 2:1.
. Stages -> 1. Fatty liver "steatosis" - 2. Hepatitis - 3. Fibrosis "Cirrhosis".
. Fatty liver is due to short alcohol use.
. Hepatitis & cirrhosis require long term use.
. Alcohol Hepatitis is characterized by:
-> MALLORY BODIES.
-> Neutrophils infiltration.
-> Liver cell necrosis.
-> Peri-venular inflammation.
. On CESSATION of alcohol intake:
-> Steatosis & hepatitis & early fibrosis are REVERSIBLE.
-> True cirrhosis (with generation nodules) are IRREVERSIBLE, regardless of
abstinence.
. HYPER-BILIRUBINEMIA APPROACH:
_______________________________
_______________________________
{A} MAINLY UN-CONJUGATED:
__________________________
. Over-production (hemolysis).
. Reduced up-take (drugs & porto-systemic shunt).
. Conjugation defect (Gilbert's $).
{B} MAINLY CONJUGATED -> EVALUATE LIVER ENZYME PATTERN:
________________________________________________________
. {1} Predominantly ++ AST & ALT:
__________________________________
. Viral Hepatitis.
. Autoimmune hepatitis.
. Drug induced hepatitis.
. Hemochromatosis.
. Ischemic hepatitis.
. Alcoholic hepatitis.
. {2} NORMAL AST & ALT & ALP:
______________________________
. DUBIN JOHNSON's $YNDROME.
. ROTOR's $YNDROME.
. {3} Predominantly ++ ALP -> Do abdominal imaging U$ or CT & Antimitochondial
Abs:
____________________________________________________________________________________
. Cholestasis of pregnancy.

.
.
.
.
.

Malignancy (pancreas - ampullary).

Cholangiocarcinoma.
Primary biliary cirrhosis.
Primary sclerosing cholangitis.
Choledocholithiasis.

. N.B. U/$ -> Biliary dilatation = Extra-hepatic cholestasis.

. N.B. U/$ -> No biliary dilatation = Intra-hepatic cholestasis.
. UN-CONJUGATED HYPER-BILIRUBINEMIA FAMILIAL DISORDERS:
_______________________________________________________
{1} GILBERT's $YNDROME:
________________________
. Disorder in conjugation.
. -- Glucuronyl transferase (enzyme that mediates glucuronidation).
. Mild jaundice.
. In-direct bilirubin < 3 mg/dl.
. Tx -> Un-necessary.
{2} CRIGLER NAJJAR TYPE - 1 $YNDROME:
______________________________________
. Disorder in metabolism.
. Severe jaundice.
. Bilirubin encephalopathy (Kernicterus).
. In-direct bilirubin 20 - 25 mg/dl. may reach 50 mg/dl.
. Normal liver enzymes & liver histology.
. IV PHENOBARBITAL -> NO CHANGE in serum bilirubin.
. Tx -> Phototherapy or plasmapharesis the LIVER TRANSPLANT.
{3} CRIGLER NAJJAR TYPE - 2 $YNDROME:
______________________________________
. Disorder in metabolism.
. Severe jaundice (less severe than type 1).
. NOOOO Bilirubin encephalopathy (Kernicterus).
. In-direct bilirubin <<<< 20 mg/dl.
. Normal liver enzymes & liver histology.
. IV PHENOBARBITAL -> ----------- in serum bilirubin.
. Tx -> Not necessary (just phenobarbital to -- bilirubin).
. CONJUGATED HYPER-BILIRUBINEMIA FAMILIAL DISORDERS:
____________________________________________________
{1} ROTOR's $YNDROME:
______________________
. Defect in hepatic storage of conjugated bilirubin.
. Normal liver function tests.
. TTT is not necessary.

{2} DUBIN JOHNSON's $YNDROME:

______________________________
. Defect in hepatic bile secretion.
. Liver biopsy -> dark granular pigment in hepatocytes (Not seen in Rotor's $).
. PANCREATIC DISEASES:
______________________
______________________
. ACUTE PANCREATITIS:
_____________________
. Severe mid-epigastric abdominal pain radiating to the back.
. Vomiting without blood - Anorexia - Tendrness in the epigastric area.
. Main causes are ALCOHOLISM & GALL STONES.
. Other causes -> Hypertiglyceridemia - trauma - infection - iatrogenic ERCP.
. Dx -> Best initial test ->
* ++ Amylase & lipase (most sensitive & specific) -> ++ Amylase/lipase 3
times.
* ABDOMINAL ULTRA$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 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.
. COMPLICATIONS OF SEVERE PANCREATITIS:
________________________________________
. 1 . Pseudocyst.
. 2 . Peri-pancreatic fluid collection.

.
.
.
.

3
4
5
6

.
.
.
.

Necrotizing pancreatitis.
ARD$.
ARF.
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 &
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:
________________________
. 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.
. DRUG INDUCED PANCREATITIS:
____________________________
. Mild & usually resolves with supportive care !
. CT scan is diagnostic.

.
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.
.
.
.

Pt
Pt
Pt
Pt
Pt
Pt

on diuretics -> Furosemide & thiazides.

on antibiotics -> Metronidazole & tetracyclines.
with IBD -> Sulfasalazine.
on immunosuppressives -> Azathioporine.
with seizures or bipolar disorder -> Valproic acid.
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
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 !!
. 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 =
Malignancy.
. Best initial test -> ABDOMINAL U/$ -> DILATED BILE DUCTS & MASS IN HEAD OF
PANCREAS.
. 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
factors.
. Bloating & dyspepsia after eating fatty foods.
. RUQ abdominal pain.
. Dx -> Abdominal U/$.
. Tx -> LAPAROSCOPIC CHOLECYSTECTOMY.
. If refused the operation -> Give ursodeoxycholic acid & advise to avoid fatty
foods.
. Asymptomatic gall stones should NOT be treated.
. Symptomatic gall stones -> LAPAROSCOPIC CHOLECYSTECTOMY.
. ACUTE CHOLECYSTITIS = ACUTE GALL BLADDER INFLAMMATION:
________________________________________________________
. CHARCOT's TRIAD -> Fever + severe jaundice + RUQ abd pain radiating to the Rt
shoulder.
. REYNOLD's PENTAD -> + Confusion + Hypotension -> (Suppurative cholangitis).
. Most commonly due to obstruction of the common bile duct by stone.
. The original incinting event is a gall stone obstructing the CYSTIC DUCT (Not
CBD) !!!
. MURPHY's SIGN -> pain on palpation of area of gall bladder fossa on deep
inspiration.
. ++ WBCs & ++ ALP (cholestasis & obstruction).
. Dx -> U/$.
. 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 &
confusion.
. 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
concern" !
. 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. 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:
____________________________
. 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.
. PORCELAIN GALL BLADDER:
_________________________
. Due to chronic cholecystitis.
. Calcium laden gall bladder.
. Calcium salts are deposited intra-murally 2ry to chronic irritation from gall stones.
. RUQ. pain with firm non tender mass in the RUQ.
. X-ray -> Rim like calcification in the area of gall bladder.
. CT -> Calcified rim with central bile-filled dark area.
. Mostly develop to GALL BLADDER CARCINOMA.
. Tx -> CHOLECYSTECTOMY.
. GALL BLADDER CARCINOMA = CHOLANGIOCARCINOMA:
______________________________________________
. Rare malignancy.
. More in hispanic or Native american females who have H/O of gall stones.
. Typicallu diagnosed during or after chlecystectomy !
. Can NOT be easily diagnosed pre-operatively.
. CA 19-9 is NOT a specific marker.
. 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:
________________________________

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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:
____________________________
. 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.
. 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 & CBD
disease.
. Most accurate test of detecting causes, location & extent of bile duct obstruction.
. Therapeutic: Stone extraction, sphincterotomy, balloon dilatation & stent
placement.
. 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.

. IMMUNOLOGIC BLOOD TRANSFUSION REACTIONS:

__________________________________________
__________________________________________
. 1 . FEBRILE NON-HEMOLYTIC:
_____________________________
. Most common reaction.
. Fever & chills.
. Within 1 - 6 hours of transfusion.
. Caused by cytokine accumulation during blood storage.
. 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.
. 6 . TRANSFUSION RELATED ACUTE LUNG INJURY:
_____________________________________________
. Respiratory distress & signs of non-cardiogenic pulmonary edema.
. Within 6 hours of transfusion.
. Caused by DONOR ANTI-LEUKOCYTE ANTIBODIES.
. 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.

Dr. Wael Tawfic Mohamed

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