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 & NEPHRO-TOXIC). . 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 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 . 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 & 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. . 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 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 $YNDROME:________________________________ . Persistent abdominal pain, nause & dyspepsia after cholecystectomy. . Biliary causes -> Retained common bile duct - cystic duct stone. . Extra-biliary causes -> Pancreatitis - PUD. . Dx -> U/$ 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 _________________________