Other liver/biliary disease

1.Primary biliary cirrhosis(PBC) Prevalence- 90% female, 40~60 yrs Presentation- Jaundice, pruritus, xanthelasma, cognitive dysfunction, steatorrhea, autoimmune disorder Lab- Cholestatic pattern, Ig M, cholesterol, AMA, Alk-p Treatment- UDCA(13~15 mg/kg/day)(bile acid move from hepatocyte into bile canaliculus), cholestyramine(2~4 hrs after UDCA)(for pruritus), colchicine, MTX, budesonide *Not used prednisolone!! 2.Primary sclerosing cholangitis(PSC) Gene- HLA-B8, HLA-DR3, HLA-DR4 Prevalence– 20~50 […]

Hepatitis

Drug induced liver injury Intrinsic (dose related) Idiosyncrasy (not dose dependent) CCl4, acetaminophen, MTX, phosphorus Isoniazid, halothane, phenytoin Symptoms- Fever, skin rash, eosinophilia Hy’s law- ALT or AST>3 fold, total bilirubin>2 fold, no other reason of liver injury→ fulfill these 3 criteria mortality rate=10% Classification Hepatitis pattern Cholestatic pattern Mixed pattern ALT>=3 ULN, R value […]

Ascites

Color Clear Turbid Bloody Milky Brown + bilirubin>40 Opalescent Cirrhosis Infection HCC, traumatic tapping, cirrhosis, malignancy, Tuberculous peritonitis Cirrhosis, malignancy Ruptured gallbladder, perforated duodenal ulcer Between turbid and milky Lab data Low Glucose- Infection, malignancy, bowel perforation High LDH- Infection, malignancy, bowel perforation High amylase- Pancreatitis, bowel perforation Malignant ascites- Peritoneal carcinomatosis, liver metastasis, HCC, […]

Lab of liver test

ALT- Less amount in liver, 47hrs half life, periportal zone, 100% in cytoplasm, injury>necrosis AST- Large amount in liver, 17hrs half life, central zone, 80% in mitochondria, 20% in cytoplasm, necrosis>injury AST/ALT<1- Chronic hepatitis, late stage of acute hepatits, obstructive jaundice, cholangitis, NAFLD AST/ALT>1- Hypoxia, liver cirrohosis, acute hepatitis, alcoholic hepatitis ALK-P(<100)- Bile canalicular membrane, […]

Ileus

1.Mechanical a)Small intestine- adhesion, hernia, gallstone ileus, intussusception b)Large intestine- tumor, volvulus, fecal impaction High location- vomiting, intermittent colic pain Middle location- crescendo colic pain Low location- fullness, feculent vomiting PE- high-pitch hyperactive bowel sound, metallic sound, borborygm X-ray- Fixed bowel gas, stack of coin sign, air-fluid levels, String of beads sign, pneumobilia(gallstone ileus), bent-inner […]

Gastric ulcer

Etiology- NSAID, H.pylori Characteristic- 5% maglinant, hemorrhage was common Corpus predominant gastritis Antral predominant gastritis HP, NSAID HP Not related to GERD Related to GERD Pain after meals Pain before meals Diagnosis- Endoscopy(a least 6 biopsy to exclude malignancy), barium examination(commonly located at lesser curvature, radiation of gastric mucosal showed benign lesion) Treatment- Like Peptic […]

Peptic ulcer

Forward- Related with MAG, DAG, MALToma Risk factor- H.pylori, NSAID/aspirin, stress, gastrinoma, blood group O, HLA-B5, smoking, CRF, liver cirrhosis, hyperparathyroidism, COPD, systemic mastocytosis, renal transplantation Presentation- Pain before meals and in the middle of the night , sudden breakthrough pain(perforation), hematemesis(bleeding), vomiting(gastric outlet obstruction) Modified Johnson classification Type Site Etiology I (60%) Lesser curvature […]

Stomach physiology

1.Vagus nerve→ M3 receptor→ Gq→ IP3/Ca→ H-K pump 2.G cells→ gastrin→ CCKb receptor→ Gq→ IP3/Ca→ H-K pump 3.G cells→ gastrin→ ECL cell→ Histamine→ H2 receptor→ Gs→ cAMP→ H-K pump 4.PGE→ Gi→ inhibit cAMP→ H-K pump *Somatostatin– Inhibit ECL cells(secretes histamine), G cells *Chief cell→ Pepsinogen I and II *Parietal cell→ HCL, intrinsic factor *Mucosal cell→ […]

Lower GI bleeding

Etiology: Anatomic (diverticulosis), vascular (angiodysplasia, ischemic, radiation-induced), inflammatory (infectious, inflammatory bowel disease), and neoplastic Presentation: Hematochezia, normal BUN/Cre Management 1.Fluid resuscitation 2.Blood transfusion- Young→ <7need transfusion, Old→ <9 need transfusion Diagnostic: Early colonscopy- within 24 hrs Imaging: 1.Radionuclide imaging– 0.1ml/min, use Tc-99m Disadvantage: Need active bleeding 2.CT angiography– 0.3ml/min Disadvantages: Need active bleeding, could not […]

Upper GI bleeding

Presentation: Melena, coffee ground in NG tube, BUN/Cre>30 Etiology: Peptic ulcer, Aorto-enteric fistula, Angiodysplasia, varices, malignancy, Mallory-Weiss tear, anticoagulant Treatment 1.Fluid resuscitation 2.Unstable→ Hct<9 need transfusion, stable→ Hct<7 need transfusion, If INR>2 or platelet count<50000 need FFP 3.Acid suppression- Esomeprazole 40 mg IV twice daily after an initial bolus of 80 mg IV 4.Prokinetic- Erythromycin(3 […]