Sickle cell pt with RUQ pain, jaundice, and increased TBili
Think what
DO NOT assume choledocholithiasis.
Think: Cholecystitis (from bilirubin stones), causing an acute sickle crisis, causing hemolysis.
This would have normal LFTs
Liver abscess
-which 2 infections to know, and their tx
- echinococcus cyst–do surgery
2. amoeba–MTX
only indication for emergeny cholecystectomy
During cholecystitis not responding to NPO, IVF, Abx.
To prevent perf
GIlbert’s, crigler najjar, dubin-johnson, rotor’s
difference
Gilbert’s, Crig-Naj: unconj Bili
Dubin-johnson, rotors: conj bili (therefore dark urine, clay stools)
AST/ALT in 1000s: ddx
6
- amanita mushroom
- shock liver (ischemia)
- tylenol OD
- acute viral hepatitis (hep A,B)–2 weeks after exposure
- autoimmune
- Budd-Chiari
Ab dx:
PBC
PSC
autoimmune hepatitis
anti-smooth muscle
ANCA
AMA
painless jaundice, think what causes (4)
-what test
CA: panc, cholangiocarcinoma, ampulla of vater
PSC, PBC
biliary strictures
Do MRCP
Pt with painless jaundice and GI bleed, think what
Ampulla of Vater cancer
Sepsis + D.Bili elevated + ALP elevated
Think what
cholestasis or gallstones.
RUQ U/S to r/o
Pancreatitis causes:
- Big 2
- next 3 to think of
stones, ETOH
trauma, hyperCa, hyperTG
order Ca+, lipid panel
also med-induced, etc
When to do CT in pancreatitis, according to onlinemeded (3 times)
CT at day1 often shows nothing.
- initial presentation and lipase low, but story is likely pancreatitis
- initial presentation of pancreatitis and sick enough to go to unit and need meropenem
- Day2-week2 to assess complications
CT can also dx chronic panc
pancreatitis pseudocyst
-tx
6/6 rule
-If <6cm and <6 weeks, allow to spontaneously resolve. rCT in 2 weeks
-If not, then surgical drainage (percutaneous, open surgery, or stomach)
Pancreatitis complications (4 to know). How to tell apart?
Time and fever/leuks.
- Abscess: 1-2 wks, fever+leuks
- Pseudocyst: 1-2 wks, NO fever/leuks
- Necrotizing panc. 1-2 days, fever/leuks. hemoconcentration
- Hemorrhagic panc. 1-2 days, NO fever/leuks. declining Hct
Necrotizing pancreatitis: tx
IVF, NPO, analgesia.
NO ABX UNTIL proven infection (may need bx)
Necrotizing pancreatitis:
- vignette, sxs
- what to do
Pt admitted for acute pancreatitis. Day 2 gets:
- renal failure
- ARDS, low sats
- hypoCa despite Ca (saponification)
- hypotensive, poor fluid response (fluid sequestration)
- early intubation
- central line for pressor support
- CXR for ARDS
- CT scan to show extent of necrosis.
- FNA bx to confirm infection, then start IV meropenem
Cirrhosis ddx
“VW HAPPENS”
Viral (hep b,c) Wilson's Hemachromatosis A1-antitrypsin PBC PSC ETOH NASH/NAFLD Something rare--eg autoimmune
PBC cirrhosis vignette
female, 40s, jaundice, cirrhosis, normal biliary imaging
SAAG score
-what is this, how to use
Serum albumin - ascites albumin
get in pts with ascites
> 1.1: Portal HTN related
- Cirrhosis
- R side HF
- Budd chiari
<1.1: not portal HTN related
- CA
- peritoneal TB
- nephrotic syndrome
- protein malabsorption
Ascites tx:
- Na
- H2O
- other
Na <2g/day
H2O <2L/day
Diuresis with spirono and Lasix.
Tap 4-6L paracentesis, albumin infusion.
Severe: TIPS
Spont bact peritonitis
- how to dx
- what bugs
- what if polymicrobial
- tx
- 250 polys after tap, with cx+
- Strep pneumo, G- rods
- if polymicrobial, not SBP. Actually secondary bacterial peritonitis from viscreal organs. Add MTZ to ceftriaxone, do ex lap.
- Ceftriaxone, with FQ ppx
hepatic encephalopathy
-tx (2)
lactulose–alters pH to trap ammonia in gut to poop out. titrate to 3-4 BMs/day
rifaximin–abx to kill gut flora, make less nitrogen
hepatorenal syndrome
-tx (3 things)
Pt has renal fail and cirrhosis, fatal.
- hold diuretics
- give albumin
- octreotide
Wilson’s disease
-how to dx and confirm
- low serum ceruloplasmin (bound to copper)
- high urine Copper
- Kayser-fleischer rings
confirm with Liver bx
Wilson’s dz
- tx
- what if refractory
- penicillamine (Copper chelator, to excrete in urine)
- transplant
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