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Pancreas, Liver, & Gallstones (Gallstones ch. 7 (choledocolithiasis …

- - - - Poor prognostic indicators for acute pancreatitis are elevated serum blood urea nitrogen level greater than 20 mg/dL (7.1 mmol/L), a hematocrit greater than 44%, or an elevated serum creatinine level.
  - - - pancreatic fluid collection, acute panc necrosis
    - - pseudocyst (resolve, >5 cm then consider drainage if symptomatic, walled off Necrosis (can get infected (air) - impenem)
  - - - calcification on plain, CT/EUS
    - - secretin test
    - - enzyme supplementation , quit smoking,
        
        rule out pseudo
    - - heavy users (>50-80 g/d) for more than 5 to 10 years
    - - PRSS1 (cationic trypsinogen)
    - - diagnostic criteria
        
        combination of five criteria: (1) cross-sectional imaging abnormalities as described in the previous paragraph and pancreatography showing duct narrowing without upstream dilation, (2) increased serum IgG4 level, (3) extrapancreatic organ involvement, (4) compatible histopathology, and (5) response to glucocorticoid therapy.
      - classic imaging
        
        sausage shaped panc, with smooth border
      - treatment
        
        glucocorticoids , immunomodulator
  - - - needle biopsy
    - - VIP insulinoma, glucogonama (necrotic erythema)
    - - tender red-purple ulcerated subcutaneous nodules
    - - palpable gallbladder due to distal bile duct compression)
    - - migratory thrombophlebitis
    - - supraclavicular lymphadenopathy
- - - - fatigue, pruritis, xanthelasma, skin hyperpigmentation, hepatomegaly, women
    - - small bile ducts that become inflamed and increased fibrosis
    - - alk phosph marked elevated, antimitochondrial Ab, increased cholesterol (HDL), increased IgM
    - - suppurative destruction of the bile ducts/ peace-meal necrosis around the ducts
    - - cholesytaramine, screen for osteoporosis (fat soluble vitamins- D), urso
  - - - IBD
    - - increased alk phos, bilirubin, p-ANCA
    - - MRCP shows multiple strictures in intra/extra bile ducts beaded
        Liver biopsy - onion skin fibrosis around the portal triad
    - - liver transplant
    - - at the time of diagnosis and every year afterward if have IBD
  - - - choledocal cysts and Senesis, PSC
    - - Ca 19-9, painless jaundice, ALK
- - - - MRCP
  - - - tx
        
        colecystecotomy
  - - - treatment
        
        abx 2. ERCP with sphincterotomy
  - - - bie duct leak
    - - choledocolithiasis
- - - - prednisone and azithioprine
  - - - Anti-HAV IgM
  - - - HBeAg+, HBV DNA> 20,000, ALT > 2x ULN
    - - interferon, entecavir, tenovir
      - which one has the highest risk for resistance?
        
        lamivudine
    - - q 6 months US, Asian men/women, with chirrosis, FH, African early, age > 40 with ALT elevation with high HBV DNA
  - - - 1992
    - - small vessel vascular, cryoglobulinemia, porphoryia cutaenea tarda (blister lesions), glomerulonephritis
    - - HCV RNA + epotypes
  - - - HbsAg, IgM core, HBeAg
    - - HbSAg, IgG Core, HBeAg
    - - HbSAg, HbC IgG
    - - HBs-Ab, HBc-IgG
    - - HBs-Ab
- - - - macrovesicular
  - - - methyldopa, nitrofurontain, phenytoin
    - - OCP, anabolic steroids, chlorpromazine, erythomycin
    - - ketoconazole, INH
    - - N-acetylcysteine
  - - - inflammation
    - - metabolic syndrome, ALT>AST, diffuse fat in the US
  - - - phlebotomy, try to get ferritin in 50
    - - liver involvement, Hyperpigmentation, Diabetes, Arthritis, and Cardiac
  - - - penicillamine
  - - - none