GI Board Review – Part II
Intestines, Liver, and Biliary Tract
March 5, 2013
Intestines
A 32-year-old man is evaluated in the emergency department for a 5-day history of worsening
crampy abdominal pain and eight to ten loose bowel movements a day. The patient has a 5-year
history of ulcerative colitis treated with azathioprine and topical mesalamine; before this episode,
he had one or two bowel movements of well-formed stool a day. The patient had sinusitis
recently, which resolved with antibiotic therapy. He has otherwise been healthy and has not
traveled recently, had contact with sick persons, or been noncompliant with medication.
On exam, temp 38.3 °C, BP 130/76 mm Hg, he is orthostatic. The abdomen is diffusely tender
without rebound or guarding. Laboratory studies reveal hemoglobin 12.3 g/dL (123 g/L),
leukocyte count of 28,000/µL (28 × 109/L) with 15% band forms. Intravenous fluids are started
and stool studies are obtained.
Which of the following is the most appropriate next
step in the management of this patient?
1.
2.
3.
4.
Increase dosage of azathioprine
Start oral vancomycin
Start oral mesalamine
Small-bowel radiographic series
55yo male with 1 month history of increasing flatulence and loose stools – BMs occurring 2-3x daily. Denies
weight loss, fever, or other symptoms. PMHx: DM2 (A1c 7%), HTN. Meds: statin, ASA, glyburide, enalapril, Ca
supplement. Has been trying to lose weight via exercise, diet, and using sugar-free snacks. Exam is normal.
Stool cultures show no growth of pathogens.
An empiric trial of which of the following is most appropriate at this time?
1.
2.
3.
4.
5.
Discontinuation of sugar-free snacks
Discontinuation of calcium supplements
Substitute Metformin for glyburide
Add acarbose to current regimen
Initiate 2-week course of Cipro
Diarrhea
• Acute (<4 weeks)
– Typically infectious etiology
• Chronic (>4 weeks)
– Infectious/Inflammatory
• IBD, C diff, Giardia, etc
– Secretory
• Carcinoid, Glucagonoma, VIPoma, etc
– Osmotic +/- malabsorption (steatorrhea)
• Celiac disease, Carb intolerance, Pancreatic insufficiency,
small bowel bacterial overgrowth, bile salt deficiency, etc
Chronic Diarrhea - Workup
Chronic diarrhea
Check stool
culture, Cdiff,
fecal leuks
Check offending meds
Laxative screen
Lactose test
Does NOT improve with NPO
Osmolar gap <50
Improves with NPO?
Stool Osmolar gap?
Stool Osm Gap:
290 – 2(Na+K)
Infectious/Inflammatory cause
Stop culprit med/supplement
Improves with NPO
Osmolar gap >125
Osmotic diarrhea
Quant fecal fat >10-24g/24h?
Yes
Secretory diarrhea
Fat Malabsoroption present
A 68-year-old man with a history of osteoporosis and alcoholism is evaluated in the emergency
department for a 7-month history of diarrhea during which he has noted an increased volume of
stool and decreased consistency. He has had intermittent abdominal pain but not severe enough
to prevent him from eating or drinking. He is not taking any medications.
On physical examination, he is afebrile; the blood pressure is 108/72 mm Hg, the pulse rate is
80/min, and the respiration rate is 16/min. The abdomen is soft with mild periumbilical
tenderness but no distention
AST 155, ALT 88, Alk phos 96, Bili 1.1, Lipase 70, INR 1.4
CT abdomen shows calcifications but no mass. Quantitative fecal fat 26g/24h.
Which of the following is the most appropriate management for this patient?
1.
2.
3.
4.
Fiber
Cholestyramine
Loperamide
Pancreatic enzymes
Fat Absorption
Gold Standard Dx: Quant fecal fat >10-24g/24h
Remember: ADEK Deficiencies
Fat Malabsorption – Few specifics
• Celiac Disease
– Suspect if signs of ADEK deficiency + iron deficiency
– Dx: gold standard – duodenal biopsy (villous atrophy)
• Antitissue transglutaminase Ab (anti-tTG) – IgA is preferred over IgG
(unless patient also with IgA deficiency) – still need to confirm with bx
• Antiendomysial IgA/IgG – more expensive
– Tx: gluten avoidance
• Small Intestine Bacterial Overgrowth
– Flatulence, bloating, diarrhea
– RFs: dysmotility syndromes (i.e. DM2), hypochlorhydria, elderly
– *Megaloblastic anemia: B12 deficiency + ELEVATED folate (due
to bacterial production)
– Low carb, high fat diet (to minimize substrate for bacteria) +
empiric Abx trial x10-14d (tetracycline, augmentin, rifaximin)
55 yo male evaluated for a 4-month history of frequent and urgent defecation with loose and bloody
stool, mild abdominal cramping, and fatigue. Has 8 BMs daily and often wakes at night with symptoms;
before this episode he had one bowel movement a day with well-formed stool. He does not have fever,
nausea, or vomiting, but he has lost 3 kg (7 lb). He has mild joint pain in his knees and ankles that also
began 4 months ago.
On physical examination, there is mild lower abdominal tenderness without rebound or guarding; there
are no palpable abdominal masses. Examination of the rectum shows gross blood.
Labs reveal microcytic anemia. Fecal leukocytes are present, but stool analysis is negative for infection.
Colonoscopy shows continuous erythema, friability, and loss of vascular pattern from the rectum to the
splenic flexure; the rest of the colon and terminal ileum is normal. Histology shows cryptitis, crypt
abscesses, and crypt architecture distortion.
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
5.
Crohn colitis
Infectious colitis
Ischemic colitis
Microscopic colitis
Ulcerative colitis
A 45-year-old woman is evaluated for a 2-week history of right leg and flank pain and a slight limp. The
patient was diagnosed with Crohn disease at age 20 years. She had an elective ileocolic resection with a
primary anastomosis when her disease proved to be refractory to corticosteroid therapy. She has since
been pain-free but has required intermittent courses of antibiotics and mesalamine for diarrheal flares of
disease. She has had routine colonoscopic examinations with biopsy specimens revealing non-necrotizing
granulomas in the colon and neo-terminal ileum. Her most recent colonoscopy was 5 years ago. She is
otherwise healthy and takes no medication.
On physical examination, the temperature is 38.0 °C, BP 120/80 mm Hg, HR 90/min; there is right-sided
abdominal tenderness and restricted painful extension of the right hip; otherwise, the range of motion of
the hip is normal and without pain. She has an abnormal gait, favoring her right leg.
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
Avascular necrosis of the hip
Crohn disease-related arthritis
Osteoporosis-related fracture of the femoral neck
Psoas muscle abscess
IBD
Crohn’s Disease
Ulcerative Colitis
•
•
•
•
•
•
•
Mouth to anus – skip lesions
Transmural involvement with
granulomas
Large volume diarrhea, steatorrhea,
+/- bloody diarrhea, abd pain
Fistulae, Strictures, abscesses
Differentiate colonic vs small
intestine involvement
•
Extends proximally from anal verge
Mucosal involvement with crypt
abscesses
Bloody diarrhea, tenesmus,
constipation, abd pain
Diagnosis: exclude infectious diarrhea
**Colonoscopy with biopsy
Serum antibodies (only assists with diagnosis):
p-ANCA: 66% of UC and 20% of Crohn’s
ASCA: 5% of UC and 50% of Crohn’s
IBD
Extraintestinal Manifestations
Colon Cancer Risk
•
•
•
•
•
•
•
Musculoskeletal
– Arthritis (nondestructive, large joint)
– Osteopenia/Osteoporosis
– Ankylosing spondylitis & Sacroilitis
Eye
– Uveitis, scleritis, episcleritis
Skin
– Erythema Nodosum
– Pyoderma Gangrenosum
Hepatobiliary
– PSC – and thus increased
cholangiocarcinoma
– Fatty liver
– Autoimmune liver disease
Heme
– Arterial and venous VTE
– AIHA
Pulm
– Serositis
•
Crohn’s – increased risk if colon
involved
UC – very increased risk
– **Start screening 8-10 years
after diagnosis
– **Rescreen 1-2 years after initial
colonoscopy
– If dysplasia seen – total
proctocolectomy
A 35-year-old woman is evaluated for symptomatic ulcerative colitis. One year ago, she was
diagnosed with pan-ulcerative colitis and responded well to initial and maintenance therapy with
balsalazide. However, 2 months ago she developed urgent bloody diarrhea several times a day
and lower abdominal cramping; prednisone, 40 mg/d, alleviated her acute symptoms, but her
symptoms have returned with prednisone tapering. The patient is otherwise healthy, and her
medications are balsalazide, 750 mg three times a day, prednisone, 15 mg/d, and calcium with
vitamin D.
On physical examination, vital signs and other findings are normal. Laboratory studies reveal
hemoglobin 11.4 g/dL (114 g/L) and plasma glucose 140 mg/dL (7.77 mmol/L). Stool analysis for
Clostridium difficile toxin A and B is negative.
Which of the following is the most appropriate next step in the treatment of this patient?
1.
2.
3.
4.
Add olsalazine
Add budesonide
Add metronidazole
Increase prednisone dosage to 40 mg/d and add 6-mercaptopurine
IBD – Treatment
Like chemo: induction of remission, then maintenance therapy
Crohn’s
UC
Surgery
Surgery
Infliximab/
Adalimumab
Cyclosporine/Inflixi
mab
Azathioprine/6-MP/MTX
Azathioprine/6-MP
Prednisone/Budesonide
Prednisone
5-ASA + Abx (only if colonic disease)
5-ASA
A 42-year-old woman is evaluated for a 20-year history of constipation. She has
approximately one or two bowel movements a week consisting of lumpy or hard stool.
She strains at defecation and has a sense of incomplete evacuation after a bowel
movement. She does not have bloody stool, abdominal pain or discomfort, weight
loss, or diarrhea. She is otherwise healthy, and her only medication is an occasional
over-the-counter laxative or stool softener.
On physical examination, vital signs are normal. The anorectal tone is normal, and on
rectal examination, the patient is able to expel the examiner’s finger when asked to
mimic a bowel movement. Laboratory studies are normal. Radiopaque marker study
shows delayed transit time through the right colon.
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
Chronic intestinal pseudo-obstruction
Constipation-predominant irritable bowel syndrome
Pelvic floor dysfunction
Colonic inertia
A 47-year-old woman is evaluated in the emergency department for 3 days of
abdominal pain, distention, and constipation. She has had nausea and vomited once.
No BM for the past 3 days. She has had similar symptoms in the past. PMHx of
systemic sclerosis. No abdominal surgeries. Meds include nifedipine for Raynaud’s and
PPI for GERD
On exam, vital signs are wnl. The abdomen is distended with hypoactive bowel sounds
and tympany. There is no succussion splash. There are no abdominal masses or
organomegaly. Labs wnl. Plain radiograph of the abdomen shows dilated loops of
small bowel. After bowel decompression with a nasogastric tube and bowel rest,
upper and lower gastrointestinal radiographic series shows no obstructive lesions.
Which of the following is the most likely diagnosis?
1. Chronic intestinal pseudo-obstruction
2. Colonic inertia
3. Gastroparesis
4. Small-bowel obstruction
Dysmotility Syndromes
• Major categories:
1.
2.
Constipation
Ileus vs Pseudo-obstruction (Ogilvie’s)
•
•
Can be acute or chronic
Etiologies: post-operative, neurologic or CT disorders, DM, hypothyroidism,
electrolyte disturbance, meds (esp narcs, CCBs), sepsis
Acute tx: NG/rectal tube, stop offending meds, replace lytes, prokinetic agents,
neostigmine (if severe) vs colonic decompression (last resort)
•
3.
Diabetic dysmotility (gastroparesis, anorectal dysfunction, and decreased intestinal motility)
•
•
•
4.
Due to autonomic dysfunction -> can lead to bacterial overgrowth
Cause cause both diarrhea and constipation
Tx: loperamide +/- clonidine for diarrhea; abx for bact overgrowth
IBS
•
•
•
•
Diarrhea predom vs constipation predom vs mixed (but always a combination)
Associations: depression, anxiety, sexual abuse, phobias, somatization
Dx – clinical and based on Rhome III criteria and absence of alarm features
Tx – symptomatic – bulking agents, loperamide, antispasmodics, TCAs, etc
Constipation Workup
Rule out secondary
causes
Rule out IBS (if
suspected)
Functional
Constipation
Slow Transit
(Colonic Inertia)
Good anorectal manometry
++Finger poop test
Normal defecography
Slow Transit Marker Study
Dyssynergic Pelvic Floor
Dysfunction
(Outlet Delay)
Poor anorectal manometry
Negative Finger poop test
Abnormal defecography
Normal Transit Marker Study
A 74-year-old man is evaluated in the hospital for severe diffuse abdominal pain. He was
hospitalized 5 days ago for chest pain and was found to be in rapid atrial fibrillation and a
myocardial infarction was diagnosed. He underwent cardiac catheterization and double stent
placement after which he has had intermittent hypotension and has remained in atrial fibrillation
with a controlled ventricular rate.
At the bedside the patient is sweating, nauseated, and holding his abdomen. He cannot respond
to questions. His wife says that he has never had any gastrointestinal problems, but that he has
not had a bowel movement since he entered the hospital. His medications are heparin,
metoprolol, simvastatin, clopidogrel, and aspirin.
On exam, temp is 38.0 °C, BP 102/60 mm Hg, HR 94/min, and RR 25/min. There is mild, diffuse
abdominal tenderness to palpation without rebound or guarding. Radiograph of abdomen shows
no evidence of perforation or obstruction.
Which of the following would be the most appropriate management for this patient?
1.
2.
3.
4.
CT arteriography
Colonoscopy
Intravenous famotidine
Lactulose
A 75-year-old woman is evaluated in the emergency department for the acute onset of passage
of bright red blood per rectum. This morning she had crampy abdominal pain and had two
episodes of diarrhea after which she passed bright red blood. The patient has a history of
hypertension and coronary artery disease, and her medications are aspirin, ramipril, metoprolol,
and simvastatin. She is otherwise healthy and has not traveled recently or taken antibiotics. She
had a colonoscopy 6 months ago, which was normal.
On exam, the patient is not in acute distress; temp is 36.8 °C, BP 130/80 mm Hg, HR 70/min, and
RR 14/min. The abdomen is soft with tenderness in the left lower quadrant without rebound or
guarding. Rectal examination shows the presence of bright red blood. CT scan of the abdomen
and pelvis shows segmental thickening in the sigmoid colon.
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
5.
Crohn disease
Cytomegalovirus colitis
Irritable bowel syndrome
Ischemic colitis
Peptic ulcer disease
Intestinal Ischemia
Mesenteric Ischemia
Acute: sudden abd pain out of
proportion to exam; appear VERY ILL
=\
Ischemic Colitis
Mild abdominal pain
++Bloody diarrhea
Intestinal Ischemia
• Acute Mesenteric Ischemia (small bowel)
– Chronic (Intestinal Angina) – in pts with vascular disease
• Postprandial abd pain, fear of eating, wt loss
• Dx: MRA or CTA; Tx: perc antioplasty/stent
– Acute – typically has precipitating cause
• Etiologies:
–
–
–
–
SMA embolus (50%) – usually due to Afib
SMA thrombis – progression of chronic ischemia; also after abd trauma or infection
Nonocclusive (25%) – physiologic vasoconstriction in response to shock
Acute mesenteric vein thrombosis – younger patients with hypercoag states
• Dx: Angiography; Tx: IVF, Abx, surgery
• Ischemic Colitis (watershed areas of colon)
– 90% in patients >60yo
– Occurs if colonic hypoperfusion
• Usually L-side (supplied by IMA)
• If R-sided involvement, likely also will see mesenteric ischemia (b/c SMA
supplies proximal colon and mesentery)
– Dx: Colonoscopy; Tx: IVF + Abx
A 34-year-old man is evaluated as a new patient. He is asymptomatic and has no
significant medical history, but he is concerned about his risk for colon cancer. His 59year-old mother had two adenomatous polyps detected at the age of 52 years. She
has had surveillance colonoscopy every 3 years since then and has had two additional
polyps detected. His father has no history of colon polyps, and there is no family
history of colorectal cancer.
On physical examination, vital signs are normal; BMI is 21.5; the rest of the physical
examination is normal. Laboratory results are all within normal limits.
Which of the following is the most appropriate screening strategy for this patient?
1.
2.
3.
4.
5.
Colonoscopy at age 40 years
Colonoscopy at age 42 years
Colonoscopy at age 50 years
Fecal occult blood testing at age 40 years
Fecal occult blood testing at age 50 years
Colon Cancer
• Screening:
– When?
• If no FHx: 50yo (unless AA, then 45yo)
• If 1st degree relative with colon CA or adenomatous polyp at age <60: start age 40 or 10 yrs
younger than affected individual
– How?
•
•
•
•
Colonoscopy q10 yrs if normal
Flex sig q5 yrs if normal
Annual FOBT
Other: double contrast barium enema, CT colonography (only if cannot due other methods)
• Hereditary Syndromes:
– FAP (Auto dominant; APC gene) – 100% Risk
• Start screening age 10 -> total colectomy once polyposis develops -> then start looking for
duodenal CA
– HNPCC (Auto dominant; MLH1 or MLH2 gene)
• Family hx of Colon, Ovarian, Endometrial CA amongst others
– Gardner Syndrome (FAP variant) – often associated with osteomas
– Peutz-Jeghers
– Juvenile Polyposis Syndrome
A 74-year-old man is evaluated for a 2-month history of recurrent melena. He has had recurrent 2
- or 3-day periods of black, tarry stool followed by normal stool for the next week. His most
recent black stool was yesterday. During this time, he has developed anemia and required
transfusions of a total of eight units of blood. He has not had chest pain, abdominal pain, nausea
or vomiting, or bleeding. The patient’s medical history includes hypertension and mild chronic
obstructive pulmonary disease.
His exam (including vital signs) is benign except for rectal examination which reveals black, tarry
stool that is positive for occult blood. Laboratory studies reveal hemoglobin of 8.6 g/dL (86 g/L)
with a mean corpuscular volume of 80 fL. EGD on two occasions and a colonoscopy fail to
identify a bleeding source.
Which of the following is the most appropriate next step in the evaluation of this patient?
1.
2.
3.
4.
5.
CT angiography
Double-balloon enteroscopy
Intraoperative endoscopy
Small-bowel barium examination
Wireless capsule endoscopy
GI Bleeding
• Upper GI bleed (Variceal vs non-variceal)
• Lower GI bleed
• Obscure GI bleed – recurrent blood loss without identified source
despite investigation with EGD/colonoscopy
– DDX based on age:
• <20: Peutz-Jeghers, Meckel’s diverticulum, Hemangioma, congenital AVM, dieulafoy
• 20-60: Crohn’s, radiation/NSAIDs, cameron erosion, meckel’s, GAVE, dieulafoy,
tumor
• >60: amyloid, AVMs, malignancy, all in 20-60 group
– Dx:
• Repeat EGD/Colonoscopy
• Capsule endoscopy – ***test of choice following negative scopes
• Double-balloon enteroscopy – if suspect small bowel lesion but negative capsule
study; can also be used to treat small bowel lesions found during capsule
• Push enteroscopy – often used to treat prox small bowel lesions found on capsule
• Angiography – if brisk, overt bleeding; can also use to treat
• Tagged RBC scan – can detect bleeding at a slower rate than angiography, but still
need lesion to be actively bleeding to detect it
Hepatobiliary
Acute Liver Injury
(Acute onset of elevated transaminases and coagulopathy in
patient with no known underlying liver disease)
Fulminant Liver Failure
(ALI + encephalopathic)
Acute Liver
Injury
Biliary
abnormality
Viral hepatitis
Autoimmune
disease
Alcoholic
Hepatitis
Metabolic
Disease
Hemodynamic
Drug-Induced
Fatty Liver of
Pregnancy
A 55-year-old man is hospitalized for a 2-week history of jaundice and altered mental status. The
patient has a 10-year history of alcohol dependence and has failed several attempts to stop
drinking. His family reports that he had been drinking heavily every day until about 3 weeks ago.
On physical examination, the patient is confused and lethargic; the temperature is 38.0 °C (100.0
°F), the blood pressure is 90/60 mm Hg, the pulse rate is 120/min, and the respiration rate is
30/min. The BMI is 24. Examination reveals scleral icterus. There is no guarding on palpation of
the abdomen. The liver edge is tender and easily palpable 3 cm below the right costal margin.
There is no ascites, edema, or evidence of bleeding.
WBC 17000, Plt 103000, INR 4.0, Bili 37.0, AST 98, ALT 50, Alk phos 230, Albumin 2.0. Ultrasound
shows enlarged, fatty liver with no nodules, ascites, pericholecystic fluid, or bile duct dilatation.
Blood and urine cultures are negative.
In addition to enteral nutrition, which of the following is the most appropriate management for
this patient?
1.
2.
3.
4.
Ceftriaxone
Methylprednisolone
Fresh frozen plasma
Liver transplantation
Alcoholic Hepatitis
• Often presents with leukocytosis, jaundice,
hepatomegaly, and RUQ pain
• **need to rule out infection
• Discriminant Function (DF)
DF = 4.6 (PT – control PT) + bili
– If >32, patient has 50% mortality in 30 days
• Candidates for steroids (typically after liver biopsy)
• Consider pentoxifylline (trental) to prevent
hepatorenal syndrome
A 25-year-old woman is brought to the emergency department by her husband for yellowing of
the eyes and increasing confusion and somnolence. The patient is 30 weeks’ pregnant and just
returned from visiting her parents in Africa. She has been previously healthy and takes only
prenatal vitamins. Previously a social drinker, she stopped consuming alcohol entirely at the onset
of her pregnancy.
On physical examination, the temperature is 37.2 °C (99.0 °F), the blood pressure is 90/40 mm
Hg, the pulse rate is 100/min, and the respiration rate is 12/min; the BMI is 20. Examination
reveals a gravid uterus and asterixis
Hgb 14, WBC 15000, Plt 450k, INR 4.7
Bili 12.0 (direct 9.0), AST 3000, ALT 2870, Alk phos 400, Albumin 2.3
Hep A IgM negative, Hep B surface Ag negative, Hep B viral PCR negative, Hep C virus Ab negative,
ANA negative, anti-smooth muscle Ab negative, AMA negative, alcohol negative, HSV PCR
negative
Which of the following is most likely cause of this patient’s
fulminant hepatic failure?
1.
2.
3.
4.
Acute autoimmune hepatitis
Acute alcoholic hepatitis
HELLP syndrome
Hepatitis E virus infection
A 20-year-old woman is evaluated in the emergency department for a 2-week history of malaise,
fatigue, and mild jaundice. The patient has no significant medical history, but she uses injection
drugs. She drinks alcohol socially.
On physical examination, the temperature is 37.8 °C (100.0 °F), the blood pressure is 128/70 mm
Hg, the pulse rate is 100/min, and the respiration rate is 16/min. Examination reveals slight scleral
icterus, needle puncture marks in the antecubital fossae, and hepatomegaly; there is no
splenomegaly, cutaneous angiomata, ascites, or asterixis
Bili 4.6, AST 580, ALT 750, Alk phos 145, Albumin 4.2, Hep B surface Ag negative, Hep B core Ab
negative, Hep C virus Ab negative, Hep A antibody negative, drug and alcohol screen negative.
Ultrasound shows hepatomegaly.
In addition to screening for HIV infection, which of the following is the most appropriate next
diagnostic test?
1. Hepatitis B virus DNA
2. Hepatitis C virus RNA
3. Liver biopsy
4. MRI of the liver
Viral Hepatitis
Acute infection: fatigue, malaise, abd symptoms, jaundice
•
HepA
–
–
–
•
HepB
–
–
–
•
Transmitted fecal/oral route
Dx: Hep A IgM (stays + for 6 mo)
Vaccinate if: traveling to endemic area, IVDU, MSM, chronic liver disease
Transmitted blood/body fluid contact or perinatal
Dx: serologies (see next slide)
Vaccinate all!
HepC
–
–
Most common bloodborne infection in the US
Dx: HepC virus RNA (active infection), anti-HCV (past exposure)
•
•
HepD
–
–
–
•
Anti-HCV can be falsely + in rheum disease -> can check HCV RIBA to confirm viral clearance if anti-HCV is positive and
HCV RNA negative
Depends on HbsAg for its replication
RF: IVDU
Can present as acute hepatitis in HepB pt (coinfection) or exacerbation of preexisting chronic hepatitis
(superinfection)
HepE
–
–
RF: underdeveloped countries; fecal-oral transmission
Severe disease seen in PREGNANT folk
Have
disease;
Not yet
immune
HbsAg
Hep B
Host
immune
HbsAb
Exposed
(acutely)
Anti Hbc
(IgM)
Exposed
(remotely)
Anti Hbc
(IgG)
Virus
VERY
active
HbeAg
HbeAb
HbDNA
Acute
Chronic,
nonreplicative
Chronic,
replicative
Immune, prior
infxn
Vaccinated
• Acute HepB infection typically resolves in 6 months -> if persistent HbsAg after 6
months, then considered chronic HepB infection
• Window period: time between clearance of HbsAg and development of HbsAb – during
this time, only Anti-Hbc present
Viral Hepatitis
Hep B
HepC
Active
Infection
Active
HepC
Chronic (5%)
Chronic
(80%)
Cleared
Cirrhosis
(20-25%)
Nonreplicative
HCC
(5%/year)
Replicative
(25%)
•
•
15-40% of chronic HepB develop Cirrhosis or
HCC (do NOT need cirrhosis prior to HCC)
US and alpha-fetoprotein q6-12 mo in all pts
with chronic HepB
Cleared
(20%)
•
•
Need Cirrhosis prior to HCC in HepC
Only need to screen for HCC in those with
known cirrhosis
Hep B – Which stage of infection?
HbsAg HbsAb antiHbC HbeAg
•
•
•
•
•
•
Window Period
Acute infection
Vaccinated
Immune, prior infection
Chronic nonreplicative
Chronic replicative
+
+
+
+
+
-
+
+
+
+
+
+
+
A 38-year-old woman is evaluated for elevated results of liver chemistry tests detected in an
evaluation for new-onset fatigue, joint pains, and jaundice. The patient recently started a job in a
hospital and received a hepatitis B vaccination. She has a history of hypothyroidism, and her only
medication is levothyroxine. She has never used illicit drugs and does not drink alcohol. Her
mother has rheumatoid arthritis.
On physical examination, the patient is afebrile; the blood pressure is 130/75 mm Hg, the pulse
rate is 80/min, and the respiration rate is 14/min. The BMI is 26. There is scleral icterus; the rest
of the examination is normal
WBC 3400, Bili 6.0, Direct bili 3.6, AST 890, ALT 765, Alk phos 100, ANA 1:40, Anti-smooth muscle
Ab 1:640, AMA negative. Viral serologic tests negative. Abdominal ultrasound shows normal
gallbladder.
Which of the folloiwng is the most likely diagnosis?
1.
2.
3.
4.
5.
Acute cholecystitis
Autoimmune hepatitis
Drug-induced liver injury
Primary biliary cirrhosis
Primary sclerosing cholangitis
Autoimmune hepatitis
• More common in women; most are
asymptomatic; often seen with other
autoimmune history
• Elevated bili, AST/ALT; Alk Phos near normal
• AutoAbs: ANA, SMA, anti-LKM1
• Dx: biopsy showing lymphocytic & plasmacytic
periportal infiltrate
• Tx: consider if 5-fold increase in transaminases
with acute inflammation on bx
– Prednisone +/- azathioprine until remission
A 57-year-old man is evaluated for elevated LFTs detected on evaluation for fatigue. The patient
has a history of osteoarthritis, Dm1, and hypertension. The patient does not use illicit drugs,
alcohol, or tobacco; he has never had a blood transfusion. His mother died of heart failure and a
maternal aunt died of cirrhosis of unknown cause.
Exam is benign and there are no stigmata of chronic liver disease
Hgb 14, Glc 145, Bili 1.2, AST 75, ALT 88, Alk phos 120, Albumin 4.2, Ferritin 1267, Transferrin
saturation 75%
Viral hepatitis serologies negative; ANA, anti-smooth muscle, and AMA negative
Which of the following is the most appropriate next step in the management for this patient?
1.
2.
3.
4.
Deferoxamine therapy
Genetic testing for mutations of the HFE gene
MRI abdomen
phlebotomy
Metabolic Liver Disease
•
Non-alcoholic fatty liver disease
1.
Nonalcoholic steatohepatitis (NASH)
•
•
2.
•
Steatosis (fatty degeneration)
Wilson Disease (autosomal recessive)
–
–
–
–
•
Obese, dyslipidemia, DM2
Tx: RF modification
Genetic defect causing copper transport abnormality thus Cu accumulates in body
Liver, neuro, psych, ophtho, BM
Dx: biopsy, decreased ceruloplasmin, increased urinary copper
Tx: chelators (penicillamine and trientene) or agents to decrease absorption (zinc)
Hereditary Hemochromatosis (HFE gene mutation)
– Iron overload (high ferritin) – liver, heart, pancreas, pituitary (bronze diabetes)
– Dx: 1) fasting transferrin saturation >50% in females or >60% in males
2) genetic screening for HFE gene mutation
3) liver biopsy to determine degree of fibrosis
– Tx: phlebotomy
•
Alpha-1 Antitrypsin Deficiency
– Accumulation of abnormal variant A1AT in body – lung, liver, skin
•
Seen as PAS+ inclusions on liver biopsy
– Increased risk of HCC and cirrhosis
– Tx: transplant if decompensated disease
A 55-year-old woman is evaluated for a 4-month history of progressive fatigue and pruritus. She
is otherwise healthy and takes no medications.
On physical examination, vital signs are normal; BMI is 25. Examination reveals mild
hepatomegaly and excoriations of the skin. There is no jaundice, rash, or skin eruption
Bili 1.5, AST 60, ALT 75, Alk Phos 470, Albumin 4.0, Hep C Ab negative, Hep B sAg negative
Ultrasonography of the abdomen is normal with no bile duct dilatation.
Which of the following is the most appropriate next step in the diagnosis of this patient?
1.
2.
3.
4.
A1AT phenotype
Liver biopsy
Measurement of serum AMA
SPEP
Cholestatic Liver Disease
fatigue, pruritis, jaundice, cholestatic LFT pattern, ADEK deficiency
• Primary Biliary Cirrhosis
– Autoimmune inflammation of ducts -> blocks bile -> destroys liver cells ->
cirrhosis
– “Cirrhosis” = think liver (thus only intrahepatic ducts affected)
– Dx: +AMA, elevated IgM
– Tx: Ursodeoxycholic Acid (esp if early stage) to decrease bile production
• Primary Sclerosing Cholangitis
–
–
–
–
Duct inflammation -> fibrosis
80% have ulcerative colitis
10% develop cholangiocarcinoma
“Cholangitis” = biliary system (thus all ducts - both intra and extrahepatic involved)
– Dx: ERCP – multifocal strictures
• Large bile duct obstruction
• Drug induced cholestasis
• Infiltrative disease (i.e. sarcoidosis)
A 57-year-old woman is evaluated for a 1-month history of increased abdominal girth. The
patient has a 15-year history of alcohol abuse, drinking a bottle of wine a day. She also has type 2
diabetes mellitus, hypertension, and hyperlipidemia, and her medications are metformin,
hydrochlorothiazide, propranolol, simvastatin, and aspirin.
On physical examination, the temperature is 37.1 °C (98.8 °F), the blood pressure is 90/50 mm
Hg, the pulse rate is 99/min, and the respiration rate is 13/min; the BMI is 21. Examination
reveals scleral icterus; bulging flanks; a small umbilical hernia; caput medusae; spider angiomata
of the face, arms, and chest; and mild asterixis. There is no abdominal tenderness
WBC 5200, Plt 65000, INR 2.2, Bili 3.4, AST 120, ALT 65, Alk phos 196, Albumin 2.7, Creat 2.7,
Urinalysis normal. Blood cultures negative.
Which of the following is the most appropriate management for this patient?
1. Diagnostic paracentesis
2. Cefotaxime and albumin
3. Furosemide and spironolactone
4. Transjugular intrahepatic portosystemic shunt
A 57-year-old woman is evaluated in the intensive care unit for rapidly progressive renal failure
requiring dialysis. The patient had been hospitalized for advanced liver disease due to Hep C
including mental status changes secondary to encephalopathy. She has ascites. The patient has
no history of renal insufficiency and has not received antibiotics, intravenous contrast agents, or
other nephrotoxic agents. Her medications are lactulose, nadolol, midodrine, octreotide, and
albumin. She does not drink alcohol.
On physical examination, the temperature is 36.6 °C (97.8 °F), the blood pressure is 110/70 mm
Hg, the pulse rate is 97/min, and the respiration rate is 12/min; the BMI is 22
Creat 5.4, BUN 120, Urine sodium <5, urinalysis negative. Renal ultrasound shows normal size
kidneys and no obstruction.
Which of the following is the most appropriate management for this patient?
1.
2.
3.
4.
5.
Add lisionpril
Kidney and liver transplantation
Kidney transplantation
Liver transplantation
Peritoneovenous shunt
Complications of Cirrhosis
•
Portal Hypertension
–
Varices
•
•
–
All cirrhotics need screening – place on bblocker if they are present
If bleed: to ICU, PPx Abx, Octreotide (splanchnic constrictor), EGD for band ligation
Ascites (SAAG >1.1) – treat with low na diet and diuretics
•
SBP (ANC >250 or + cultures)
–
•
•
–
Hypoxemia due to intrapulmonary shunt
Dx with Echo and bubble study
Tx: liver transplant
Encephalopathy
–
–
–
•
Result of splanchnic vasodilation and thus activation of renin-angiotensin system thus renal vasoconstriction
Dx of exclusion; Urine Na <10 in absence of intrinsic renal injury
Type 1 – acute progression (2 wk mortality 80%); Type 2 – more indolent, usually in setting of diuretic resistant ascites,
better prognosis
Tx: systemic vasoconstrictor (midodrine) + splanchnic vasoconstrictor (octreotide) + albumin + liver transplant
Hepatopulmonary Syndrome
–
–
–
•
Diuretic resistant ascites – need occ LVP
Hepatorenal Syndrome
–
–
–
•
Tx 3rd gen ceph x 5 days
Due to elevated glutamine in brain 2/2 elevated ammonia -> brain edema
Precipitants: bleed, dehydration, electrolyte abnorm, over-diuresis, SBP, renal failure, TIPS
Tx: Lactulose (to decrease gut ammonia), Rifaximine
HCC
–
–
–
–
No need to biopsy (could seed the tumor)
Dx: imaging + elevated alpha-fetoprotein
Local ablative therapy (if 2 or less tumors all <3cm in size): RFA, Perc EtOH ablation, TACE
Resection if: one tumor <5cm or 3 or less tumors all <3cm
A 65-year-old man is evaluated in the emergency department for fever and abdominal pain. The
patient has a history of diverticulitis, and his latest flare 2 months ago was treated as an
outpatient with antibiotics. While improved, he still has residual pain in the left lower quadrant.
He has no other significant medical history and has not traveled recently.
On physical examination, the temperature is 38.8 °C (101.8 °F), the blood pressure is 120/85 mm
Hg, the pulse rate is 100/min, and the respiration rate is 18/min; the BMI is 25. There is right
upper quadrant abdominal pain with normal bowel sounds and no peritoneal signs, scleral
icterus, or ascites.
Hgb 14.2 WBC 17,000 with 15% bands Plt 320,000 INR 1.0
Total Bili 1.6
Direct bili 0.6
AST 97
ALT 86 Alk phos 220
CT scan of abdomen/pelvis shows mass with fluid level consistent with a hepatic abscess. Abx are
started.
Which of the following is the most appropriate next step in the management of this patient?
1.
2.
3.
4.
ERCP
Lobectomy
MRI with gadolinium
Perc drainage of the hepatic lesion
Liver abscess
& cysts
•
•
•
•
•
Hepatic Abscess (consider in workup of FUO)
– Pyogenic (E.coli, anaerobes, Klebsiella)
• Often from direct seeding of intraabd process of hematogenous spread
• Need Abx and PERC DRAINAGE
– Amebic (Entamoeba histolytica - recent travel to Mexico or South America; HIV
also risk factor)
• Treat with Flagyl if E. histolytica; NO DRAINAGE REQUIRED
Hepatic cysts – usually asymptomatic; only resect if large and causing symptoms
Cystadenomas (thicker irregular walls) – can undergo malignant transformation, need
resected
Focal Nodular Hyperplasia – benign; central scar; don’t need to
stop OCPs as it is not hormone responsive
Hepatic Adenomas – rare malignant potential; are hormone
responsive so need to stop OCPs; high risk of bleeding esp in
pregnancy so resect prior to pregnancy