Code Orange
Charcot's Triad
upper abdominal pain, fever and jaundice
Medical therapy to assist with alcohol use disorder
What is the main cause of HCC
HBV infection-can occur in the absence of cirrhosis
Cirrhosis secondary to chronic hepatitis C, annual incidence of HCC is 1%-8%, in patients with chronic HBV the annual incidence is 1%-15%
How common is liver cirrhosis present in cases of HCC in Western countries?
cirrhosis is present in 90% of patients with HCC, most of the presenting symptoms are due to cirrhosis rather than underlying carcinoma
What labs would you get if evaluating a patient with cirrhosis in the ED
CBC-thrombocytopenia, anemia
INR, ammonia, bilirubin, albumin
BMP-hyponatremia
Reynold's pentad
(right upper quadrant pain, jaundice, and fever) with shock (low blood pressure, tachycardia) and an altered mental status
What is it called when an alcohol use disorder pt starts having persistent alteration of consciousness and sympathetic hyperactivity due to alcohol withdrawal
What is Delirium Tremens
(onset is usually 72-96hrs)
What is the screening modality for HCC
Ultrasound every six months
Presenting symptoms of patients with HCC
1. Primary: mild to moderate upper abdominal pain, weight loss, early satiety, or a palpable mass in the upper abdomen
2. Paraneoplastic syndromes: hypoglycemia, erythrocytosis, hypercalcemia
3. obstructive jaundice (rare)
What percentage of American patients with RCC have resectable disease?
5%
ideal patient for resection has a solitary HCC confined to the liver that shows no radiographic evidence of invasion of the hepatic vasculature, no evidence of portal hypertension, and well-preserved hepatic function, CP A
stage IIIB, IVA, or IVB disease to be incurable by resection. These stages are defined by invasion of a major portal or hepatic vein, direct invasion of organs other than the gallbladder, perforation of the visceral peritoneum, and nodal as well as distant metastase
30 yo female with BMI of 30, six hours of mid-epigastric pain, radiating to right shoulder. tachycardia and mid-epigastric pain. AST 180, ALT 190, Alk P 200, Bili 5.0. US showing dilated common bile duct, contracted gallbladder, no visible stone. RUQ showing dilated CBD, contracted gallbladder, no stone
What is choledocholelithiasis
How many hours after cessation of alcohol can a pt have uncomplicated onset of alcohol withdrawl (anxiety, tremor, headache, n/v, sweating, etc)
What is 6-24hrs
Who should receive screening for HCC
1. patients with cirrhosis, Child-Pugh class A and B
2. patient with cirrhosis and CP class C awaiting liver transplantation
3. Noncirrhotic patients with hepatitis B virus and any of the following: active hepatitis, family history, african americans, asian males>40, females>50
What is an elevated AFP
AFP>20 ng/ml is a commonly used threshold to trigger evaluation for HCC
In a study with 1800 patient with chronic liver disease AFP>20 has 60% sensitivity and 80% specificity
Which patients can qualify for liver transplant
eligible patients have a solitary HCC ≤5 cm in diameter or up to three separate lesions, none of which is larger than 3 cm; no evidence of gross vascular invasion; and no regional nodal or distant metastases (the Milan criteria)
44 yo male with AUD, recently sober, recent admission for alcoholic hepatitis admitted to your clinic. With spider angiomas and palmar erythema. ALT 28, AST 31, Alk P 31, T bili 1.3, Alb 2.9, Plt 101k. Next step?
EGD to screen for esophageal varices
varices grade 2 or higher, ppx BB
no varices screening EGD 2-3y
What is the scale system we use to monitor alcohol withdrawal?
CIWA
(>9 score may require the start of ativan)
Name five sequelae of cirrhosis
ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal bleeding, and hepatorenal syndrome
What are the five categories of a child-pugh score
Ascites, Encephalopathy, Bilirubin, Albumin, INR
Child–Pugh A = 5–6 points, Child–Pugh B = 7–9 points, Child–Pugh C = ≥10 points
Treatment for HCC with CPB or CPC
Radiofrequency ablation, microwave ablation, cryoablation, arterial embolization +/- TACE (chemotherapeutic agent, with or without lipiodol or a procoagulant material, into the hepatic artery)
Antibiotics for a patient complaining of fever, RUQ, with an obstructing stone on US
piperacillin/tazobactam (Zosyn, 3.375 g IV q6h or 4.5 g IV q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or meropenem (Merrem, 1 g IV q8h)
What are the three benzos that are given to alcohol withdrawal pts because they are less toxic to the liver?
What is Lorazepam, Oxazepam, and Temazepam
Patient with MDD, AST 105, ALT 120. HEp B surface antigen and core ab positive, neg hep B surface antibody or e antigen. HB DNA viral load 50,000. Tx?
if HBV viral load >2000 and AST is greater than 2x upper limit of normal. start tenofovir or entecavir
interferon avoided in depression
What can be used in substitution for a liver biopsy in high risk patients
LI RADS
(non-rim) arterial phase hyperenhancement
nonperipheral "washout": a visual assessment of relative hypointensity of the lesion compared with background liver on the portal venous and delayed phases
enhancing capsule/pseudocapsule
threshold growth: diameter increase ≥50% increase in ≤6 months
Percentage of risk for adverse complication in liver biopsy
2.4%