Fetor hepaticus - foul smelling breath of a patient in late liver failure Ascites fluid normally contains isotonic Glucose, Sodium, Potassium, but Increased protein (up to 3 gm/dL) Ascites caused determined by the SAAG (Serum albumin)-(ascites albumin) • Values greater than 1.1 indicate portal hypertension as increased capillary hydrostatic pressure forces fluid into the interstitium leaving behind proteins (albumin) • If serum albumin is low with an elevated SAAG, this indicates liver damage • High serum protein in the setting of SAAG indicates Heart Failure or Budd Chiari Hepatitis A virus is a (+)non-enveloped, ss-RNA virus of the family: Picornaviridae that causes a self-limited serum-sickness-like illness • Spread fecal-orally • Does not cause Cytotoxic damage; rather immune mediated • Patchy areas of inflammation • Anti HAV Ab IgM appears at onset of sx’s (approximate month incubation) Hepatitis B virus is a Circular dsDNA Virus • Long incubation period of 1-4 months • Parenteral, Sexual, and perinatal transmission (highest risk of carrier state and HCC genesis) • Codes for HBVx gene which may be associated with HCC genesis based on interference with p53; Required for infectivity • Also contains a DNA Polymerase with Reverse Transcriptase Activity • Chronic Infection has been associated with Polyarteritis Nodosa, and Glomerulonephritis Hepatits C Virus is a (+)ssRNA of Flaviviridae • only 25% are capable of clearing the infection and the majority will go on to a stable cirrhotic condition • of these a smaller percentage will progress to worsening cirrhosis or HCC • Rare acute viral stage • presence os HCV Ab DOES NOT confer resistance (as in HBsAb) • Transmission via blood innoculum Hepatitis D virus is a defective-circular ssRNA of Deltaviridae • requires concurrent HBV infection • may occur simultaneously (co-infection); normally cleared • or may occur on top of chronic HBV (Superinfection) • Causes a much more rapid progression of the hepatitis • Parenteral Transmission Hepatitis E virus is non-enveloped ssRNA of Calciviridae • Fecal-oral transmission • Usually self limited diarrheal illness • Associated with a HIGH MORTALITY IN PREGNANT WOMEN Cyst water transmission is unique to protozoa (ie. Cryptosporidium, Giardia, and Entamoeba) Y. enterolitica is associated with mini-epidemics of dysentary, primarily in COLD WEATHER and children Shiga Toxin inhibits 60s Ribosomal subunit HCV can be associated with or cause Cryoglobulinemia and vasculitis Liver Abscesses • may be caused by bacteria • enterics, such as E. Coli & Klebsiella (increased in DM; more mass-like than other bact abscesses), Strep Viridans, • Requires liver dysfunction or huge innoculation (via bacteremia, infection drained via portal system, direct extension, or trauma) • Usually in the setting of obstruction causing ascending cholangitis • Requires intensive abx therapy and DRAINAGE
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• Amoebic abscesses (Entamoeba) causes an exquisitely tender liver, is associated with corticosteroid use, and responds rapidly to metronidazole • E. histolytica crosses tissue planes readily • Do not usually drain unless life threatening, pregnant, left lobe, very large • Creates a non-purulent abscess with cellular debris and organisms in the periphery Hepatic Encephalopathy can be treated with Lactulose as it chelates excess ammonium Caroli disease is a form of Congenital Hepatic Fibrosis, characterized by intrahepatic Biliary duct proliferation and ectasia • Associated with Polycystic Kidney Disease • Causes portal hypertension • Associated with a 100x greater risk of Cholangiocarcinoma Diverticulitis is associated with a thickening of the bowel wall For SEVERE Pseudomembranous colitis (ie. Acute Renal failure, Hypotension, and marked leukocytosis), Tx with Oral Vanco • for mild infections, oral Metronidazole and Vanco are equivalent Altered Lipid Metabolism in the liver is seen in the setting of Alcoholic Hepatitis as well as NASH • the result is an alteration of oxidation leading to: • decreased B-oxidation in the liver • Increased Uptake and Synthesis of Fatty Acids • decreased VLDL PSC has been associated with Positive ANCA Ab’s (also UC; hence seen together) Fibrolamellar Carcinoma is a subtype/variant of HCC in which nodules are separated by parallel collagenous lamina • seen in Hemochromatosis and Tyrosinemia Pts presenting with late onset Diabetes who are thin/malnourished, consider chronic pancreatitis Pancreatic Carcinoma follows a similar pathogenesis to that off Colon Cancer through various mutations culminating in cancer • K-Ras mutations early lead to Fos/Jun expression • p-16 mutations follow leading to a loss of G1/S checkpoint • SMAD-4 and p53 follow with unregulated growth and loss of apoptosis • Associated with a desmoplastic reaction Pre-albumin is a better marker for chronic liver disease than is Albumin Administration of Vitamin K helps diagnose Vitamin K deficiency-induced prolonged PT versus liver disease-induced prolonged PT (lack of all clotting factors except V, VIII will NOT be corrected with Vit K administration) Factor V is NOT synthesized in a Vitamin K dependent fashion and therefore can be used as a marker of recovery in liver disease Sialadenitis is caused usually by obstruction and may create an abscess from flora such as S. viridans, and aureus • May also be AUTO-IMMUNE (ie. Sjogrens) • commonly affects lacrimal and salivary glands • Mikulicz Syndrome Esophagitis is characterized by Eosinophils in the the epithelial layer, elongation of Papillae of Lamina Propria and Basal Zone Hyperplasia H. pylori infection is associated with a number of proteases and virulence factors: • VacA is a vacuolating protease translated from the CagA gene • Stimulation of IL-8 causes a massive influx of PMNs resulting in tissue damage Cholangiocarcinoma aka Klatskin Tumor Bilateral Ovarian tumors secondary to Gastric Carcinoma spread - Kruckenberg Tumor
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Stomach Adenocarcinomas may present with Acanthosis Nigricans, a paraneoplastic syndrome Chronic Alcohol INDUCES P450 (located in the smooth ER); as a result, the GGT may be elevated as Increased P450 stimulates GGt synthesis • Can be used to Monitor truthfullness regarding Alcohol intake by chronic abusers Yersinia may manifest with systemic symptoms including pericarditis, peritonitis, and pharyngitis • Necrotizing granuloma of the peyer’s patches C. perfringens has been associated with Necrotizing Enterocolitis Mucinase allows V. cholera to colonize sml intestine Shigella evades immune system by cell-to-cell transmission, even though non-motile; accomplished via actin polymerization S. tyhpi’s infectivity comes from the Vi antigen capsule it possesses UC is associatd with HLA-DRB1 mutations Crohns is associated with HLA-DD7 and DQ4 Celiac - HLA DQ2 and DQ8 Crohn’s can be identified by Fat Creeping of mesentary around bowel; • Hypertrophy and Stricture commonly show up as a “String Sign” on Barium XR The finding of Diphteroids on lab should raise suspicion of L. monocytogenes • mc. occurs in patients who have a diminished cell-mediated immunity • ie. Pregnancy (abortion/still born) • AIDS , Neonates & Eldery pts (meningitis, cerebritis, abscesses, endocarditis) • Gastroenteritis is associated with contaminated food products: • Deli meats, soft cheeses • Iron is also a growth factor • increased occurrence in Hemochromatosis patients and chronic transfusion recipients • Virulence factors include Actin-A (adhesion); Listeriolysin-O (evade phagocytosis), and Internalin (endocytosis) • Complications include DIC/ARDS/Liver Disease, and Rhabdomyolysis Dental carries - think Actinomycetes Villous blunting (ie. Giardia) cause a malabsorption leading to an osmotic diarrhea Entamoeba (invasive form) causes an ulcerating dysentery with cutaneous perianal and urogenital ulcers (flaskshaped extending into the Submucosa) • may also cause R-sided pleural effusions Microsporidia can cause a chronic cachectic wasting state similar to Cryptosporidium • the spore is small and resistant with a polar filament Loeffler’s Penumonitis can occur in the setting of Ascaris or Hookworm (Ancylostoma/Necator) infection Hookworms feed off the blood causing an Iron-deficient Anemia Strongyloides can infect through intact skin; additionally it can: • Produce multiple generations within a host • Larvae (not eggs) are found in the stool • Causes a migrating rash (larva currens) • Gram negative meningitis and auto-infection in immunocompromised patients (or using corticosteroids) • Transmitted person-person Schistosoma is a blood fluke that causes many mortalities worldwide • penetrates healthy skin • Causes acute serum-like sickness in non-endemics (Katayama Fever) • Snail is an intermediate host (all Trematodes including Liver Flukes) • Can migrate to the liver creating periportal fibrosis with hypertension but spares hepatocellular function • S. Haematobeum can also infect the bladder and cause fibrosis and even cancer • Treat with Praziquantel GIST’s may affect the small bowel
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• Associated with c-KIT mutations and stain CD-117 positive • Demonstrates spindle cells • Treat with Imatinib Fecal Leukocytes in the setting of infantile dysentery is unique to Shigella (DDx Campylobacter; pt’s NMYL < 1 y/o) • Additional complications include reactive arthritis/Reiter’s Syndrome, and Rectal Prolapse Reiter’s Syndrome can also occur in the setting of Campylobacter infection • Erythema nodosum also Zn is an important component of fluid replacement therapy • Watery diarrhea of the newborn is most likely EPEC or EAEC Paneth Cells are a hallmark of Inflammatory bowel disease (as is Pseudopyloric metaplasia) Basal plasmacytosis is characteristic of UC while Crohn’s is most often seen with a lymphocytic infiltrate Mumps can produce aseptic meningitis Celiac’s disease is associated with an increased risk of MALToma Ascaris’ life cycle involves aspirating a small worm as the eggs hatch in the lungs • Characteristic football-shaped eggs UC can be identified histologically by plasma cell infiltrate and neutrophilic crypt abscesses