IM hepatic (~c/h)

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Author:
TerryZ
ID:
249408
Filename:
IM hepatic (~c/h)
Updated:
2013-11-29 07:39:17
Tags:
internal medicine IM hepatic
Folders:
IM
Description:
Internal medicine - hepatic (other)
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  1. HCC - facts
    • Stats: 80% prim liver CA (rare in US)
    •          Most deaths worldwide (Afr/Asia)
    • Types: Nonfibromellar-MC, B/C, cirrh,
    •                   unresectable, <surv(mo's)
    •           Fibromellar-adolesc, young girls
  2. HCC - RFs
    • Any agent: ->c, low-grade liver damage
    • Cirrhosis: 10%
    • Chem carcin: aflatoxin,vinyl Cl,thorotrast
    • Defic: α-~trips, hemochrom, Wilson's
    • Parasite: schistosomiasis (trematodes)
    • Hep adenoma: 10%
    • Smoking: .
    • GSD: glycogen storage dz (type 1)
    • NASH: fatty liver dz
    • Tyrosinemia: metab error
  3. HCC - S/Sx
    • Asympt: until very large
    • Abd P: HM w/ palpable mass
    • Const: Wt loss, anorexia, fatigue
    • Hep: PHTN, ascites, jaundice, SM
    • Ausc: Liver friction rub/bruit - X!
    • Paraneopl: erythro-/thrombocytosis, HCa, carcinoid synd, HTroph pulm osteodyst, HoGly, HChol
  4. HCC - Dx
    • Bx: !X - seeds tract
    • Lab: HepB/C serology, LFTs, coag test
    • US/6mo: f/u susp mass w/CT/MRI/angio
    •              avg HCC 2x/120 days
    • MRI: "washout" - art blood->CA
    • AFP: ?/40-70%, 2x!, >1000 diagnostic
    •        HBV: 6mo
    •        HCV: 6mo after bridg fibr/cirrh 
    •        false: asc,virHep,PBC,testcCA,preg
  5. HCC - Tx
    • Resect: only 10%
    • Xplant: if dx early
    • TACE: trans-arterial chemo embolizat'n
    • Ablation: thermo/cold
    • LASER: resection
    • Sorafenib: /survival 12 weeks
  6. Jaundice - facts
    • Clinical: evident TBili>2 mg/dL
    • Causes: hemolysis,liver dz,biliary obstr
    • Bili Metab: 80% Hgb, 20% Mgb/liver enz
    •   Hgb->unconj bili (spleen)->plasma (alb)
    •   Liver} conj & excret->intestine
    •   Bact} CBili->urobilinogen+urobilin
  7. Conjugated vs unconjugated bilirubin
    • .              U-Bili     C-Bili
    • Alb bind:  tightly    loosely
    • H20-sol:     no        yes
    • Urine:       can't     dark
    • Toxic:       BBB!      non
    • Defect:   pre-hep  post-hep
  8. Conjugated HBilirubinemia - causes
    • Cholestasis: itching w/jaundice
    • Hep excr: intrahepatic
    •      HC dz: vir/EtOH hep, cirrhosis
    •      Inherit: Dubin-Johnson, Rotor's
    •      Drug: OCC, PB
    •      PSC: prim sclerosing cholangitis
    • Obstr: Extrahepatic biliary obstruction
    •      Gallstones
    •      Carcinoma of head of pancreas
    •      Cholaniocarcinoma
    •      Periampullary tumors
    •      Extrahepatic biliary atresia
  9. Unconjugated HBilirubinemia - causes
    • //prod'n: hemolytic anemias
    • uptake or impaired conj: .
    •       Gilbert's, Crigler-Jajjar 1/2 syndr; 
    •       Drugs: sulfon, PCN, rifam, contrast
    •       PJN: physiol jaund of the newborn
    •       Diffuse liver dz: hepatitis, cirrhosis
  10. Jaundice - Dx
    • Serum: T conj & T unconj
    • Conj: CBC,retic,hapto,LDH,periph smear
    • Unconj: LFTs
    • US/CT: biliary tract obstr/anatomic chgs
    • ERCP, PTC: .
    • Bx: may be indicated
  11. Cholestasis
    • D: blocked bile flow w/ /C-Bili
    • S/Sx: .
    •    Jaundice, gray stools, dark urine
    •    Pruritis (bile salt in skin)
    •    /Alkϕ, HChol/xanthomas
    •    Malabsorp fats/fat-soluble vitamins
  12. LFTs - ALT vs AST
    • _             ALT                  AST          _
    • Loc     Mostly liver   +musc,<3,kid,brain
  13. LFTs - AST/ALT/alkϕ/GGT
    • /AST:ALT: synch, except EtOH hep>2:1
    •              EtOH hep: AST<500, ALT<300
    • /: low 100s} C vir hep, acute EtOH hep
    • //: hi100s-Ks} A vir hep
    • ///: >10K} extensive hep necrosis
    •    (isch, shock liv, APAP tox, sev vir hep)
    • -: cirrh, metastat (fn-ing hepatocytes)
    • asympt: A thru I (separate card)
    • cholestatic: //alkϕ,GGT; slight/AST,ALT
    • HC nec/inflam: -/alkϕ, //AST,ALT
    • alkϕ: +bone,butt,plac; bile obstr (10x)
    • GGT: /GGT -> alkϕ hepatic in origin
  14. LFTs - albumin, PT
    • Alb: C liver dz, nephrot syn, malnutr,
    •      inflam states (burns, sepsis, trauma)
    • ->PT: advanced liver dz (synth cap lost)

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