A 65-year-old man with a history of nonalcoholic fatty liver disease is admitted to the intensive care unit with hematemesis. He has no history of gastrointestinal bleeding.
On examination, he is afebrile, with a heart rate of 110 beats per minute and a blood pressure of 90/50 mm Hg. Spider angiomata are present on his anterior chest. An abdominal examination reveals distention and bulging flanks. There is no tenderness to palpation.
Laboratory testing reveals an international normalized ratio of 1.8 and the following other results:
Alt/ast- 66/57
Albumin- 3
Total bili-3.6
Wbc 7200
Hgb/hct- 9.8/28.8
Plt 80,000
In addition to upper endoscopy, which one of the following treatments is indicated for initial acute management of this patient?
Albumin
Nadolol
N-acetylcysteine
Midodrine
Ceftriaxone
rocephin- SBP concern
nadolol is for stable pt with varices
hepatorenal syndrome- nonacute for midodrine
200
What are the diagnostic criteria for SBP diagnosis
PMN greater then or equal to 250cells/nm3
treatment is ---rocephin 2gm iv x 5days if less then cefotaxime 2gm iv q8hrs x 5days
200
what is the expected lab work in acute alcoholic vs viral hepatitis?
Viral: ALT > AST
ETOH: AST>ALT
200
Pt returned from mexico has diarrhea/cough, fevers and chills. What do you suspect? What is the treatment and imaging?
entamoeba histolytica- fecal oral from contaminated water food
cxr, US usually enough to see round mass
Treatment: flagyl 750mg TID 7-10days
rarely need to be drained
200
A patient overdoses on Tylenol which liver enzyme will be elevated??
Haldol??
What are some goals for plts, fibrinogen for gi bleed what are some treatments if these are abnormal?
plts>50k
fibrinogen >100 use cryoprecipitate
vitamin K for elevated INR
rocephin 1gm for sbp prophylaxis
300
You have a patient who had a needle stick who is unvaccinated what would you give pt?
Hep B- Give HBIG within 7-14days of exposure and HBV vaccine if unvaccinated or inadequate titer
Hep C- no prophylaxis
Hep A- Immune serum globulin 0.02ml/kg IM reserved for immune-naïve with increased risk from hepatitis/ within 2wks of foodborne exposure
300
which conditions are associated with transaminases in the 1000's?
porcelain gb most often in elderly women may be palpable but isn't usually tender. high associated of cholangiocarcinoma should be referred for surgical removal
400
what are the risk factors for acalculous cholecystitis?
elderly
admitted pts recovering from nonbiliary tract surgery
aids with secondary cmv or cryptosporidium infection
men with uncontrolled dm-----high risk for emphysematous cholecysitis
400
What is the progression of chronic alcohol use?? -------after 2 wks------, -------- after 5yrs and then can lead to ----------------
a. steatosis
b. fibrosis/cirrhosis
c. hepatocellular carcinoma
400
how can you use urine leukocyte esterase test strip in ascites?
dip it and if positive high likelihood that ascitic flid has significant neutrophils
400
What is the treatment for suspected emphysematous cholecysitis?
1.early surgery
2. rocephin 2gm iv and flagyl 500mg iv or zosyn or meropenem
400
where is hep E commonly found?
asia, African, russia
500
what is Reynolds pentad
charcots triad- ruq pain, fever, jaundice with hypotension and altered ms
500
SAAG greater then 1.1 can be indicative of?
serum ascites albumin fluid gradient can be early indicator of sbp
subtract albumin in ascitic fluid from serum albumin
500
what are some organisms that cause sbp?
ecoli, klebsiella, gram pos bacteria
500
You have a pt with ruq pain, fever, jaundice what are you concerned about?
ascending cholangitis- usually e coli, klebsiella, enterococcus bacteroides usually from duodenum
Charcots triad- RUQ pain, fever, jaundice