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Diseaes of the osphagus



digestion or absorption upper
esophgeal sphincter crico pharyngus
lower esophgeal sphincter last inch
lower part of the esophgus high tone

esophagus chest chest negative


pressure esoghagus relaxed
last inch of esophagus intra abdominal intra
abdominal pressure Positive chest
Lower part of the esopghagus already tone
high pressure gastro esophageal
reflux

esophagus stratified squamous


epitheliun lower part gastro esophageal junction


..............................................................
columnar metaplasia
columnar

lower esophageal sphincter mainly nitric oxide


relaxtion

soft palate naso pharynx
epiglottis Larynx esophagus
relaxed crico pharygeus muslce contracted
pharynx esophagus
stomach \ lower esophageal sphincter
Hernia esophageal hernia hiatus
hernia hiatus hernia defect diaphragm
sliding hernia

sliding
lower esophageal sphincter sliding
intra abdominal intrathoracic
sphincter tone
gastro esophageal reflux

para esophageal
fundus stomach diaphragm
fundus stomach
Lower esophageal sphincter


..............................................................
.N.B
esophageal hernia reflux
heart burn reflux
..............
tone lower esophageal
sphincter

reflux
H2 blocker proton pump inhibtor
see later

para esophageal fundus


stomach

Para esophageal esophageal hernia
para esophageal fundus of the stomach
chest mediastinal syngdrome


iam joking (:
fundus of the stomach
diaphragm muscular
strangulation
3


..............................................................
cut blood supply
viscous stomach gangarene
strangulated emergency

achalsia Problem
lower esophageal sphincter ) (
esophagus peristalsis

plexus nitric
oxide nitric oxide relaxation of the
sphincter injury Lower esophageal
sphincter spastic

intermittent dysphagia
dysphagia fluids solids


esophagus

aspiration

esophagus aspiration
achalsia cancer esophagus
reflux
aspiration
pnumonia right basal


..............................................................
on examination
bronchial breathing scapula

right basal
semi sitting



) (


lung abscess suppurative lung disease
GIT

infection sore throat


vincent angina

weight loss

young female dysphagia


Collagen disease

achalsia intermittent long duration



..............................................................
Investigation
air Left copula of the diaphragm

air
barium esophagus dilated
parrot peak appearance
dilated
atony in muscles sphincter
Narrowing in the lower part of the esophagus
regular and smooth benign
cancer esophagus

chest pain
abnormal esophageal contraction rather than
persistsis persistalsis esogphaus
contractions abnormal chest pain
Achalsia chest pain chest pain

achalsia Organic functional


tone
resistance mass

manometery Lower esophageal


sphincter


..............................................................
:::
ballon dilation

common used

Cancer esophagus Problem


old male prgessive dysphagia cancer
oesphagus
dysphagia short duration

cancer solid duration


cancer esophagus
weight loss
predisposing factors
smoking-1


..............................................................
Old male heavy smoker
dysphagia dysphagia

mediastinal syndrome
bronchogenic


-2
squamous cells
plammer
reflux
stratified squamous
Lower part of the esophagus starified squamous
columnar parrot esophagus
precancer
c/p
dysphagia solids short duration
cancer
weight loss

barium rat tail apperance
Mass infiltration dye
ct scan mediastinum

localized to esophagus


..............................................................
Cancer esophagus Late

Paliative chemotherapy esophagus


..... ...
stent

(gastro esophgaeal reflux disease (GERD


common lower esophageal sphincter tone
lost
stomach esophagus
esophagus motility stomach motiltiy
sphincter hiatus hernia


intra abdominal pressure
reflux lower esophageal sphincter
tone very tight

GERD motility for the
esophagus stomach motility the sphincter

esophageal motility
gastric motility sphincter


..............................................................
obesity
) ( reflux

c/p
Heart burn, chest pain
burning pain esophageal
spasm
dysphagia Pulmonary
cough larnygeal irritation

heart burn


Larynx
irritated hoarseness of voice
!!!! asthmatic reflux

investigation
endoscope PH Lower part esophagus
very low PH reflux
barium hiatus hernia

complications

10


..............................................................
esophageal erosion hematemesis meleana
stricture parrot peak esophagus
Lower part of the esophagus

simple measures
weight reduction
reflux


antacid ) (
proton pump inhibitor

reflux

) fundus
stomach lower part esophagus
abdomen ( laparoscope

Medical reflux

proton pump inhibitor


11


..............................................................
proton
pump inhibitor

proton pump inhibitor


laparoscope


GERD myocardial ischaemia

clinical

related


ischaemia GERD
Ischeamic heart GERD





psychogenic pure
motility disorder

12


..............................................................
....

Diffuse esophageal spasm


esophagus x-ray sever retro sternal chest
pain
esophagus
heart exertion dyspnea
relation to meals
dysphagia
esophagitis esophagus
chemical inflammation Candida
cytomegalovirus immune comprised
esophagitis pills induced


esophagus
...
......
esophagus


esophagus

esophagus proton pump inhibitor



100
120
13


..............................................................

esophagus
perforation of the esophagus ) (
Mallory -Weiss tear
tear gastro esophageal junction common in
alcoholic conservative treatment

esophagus

mediastinum
sever agonizing pain acute
medistinmitis esophagus

(esophageal web (plumberVinsonsyndrome


ring in the esophagus fibrous tissue ring in
esophagus dysphagia iron deficiency anemia
association between dysphagia and iron deficiency
anemia fibrous tissue in esophagus
PlummerVinsonsyndrome

14


..............................................................

k1revision.1aim.net
Liver anatomy Liver segments
mcq
histology space space
blood sinusoids hepatocytes
cells tissue macrophages
blood monocytes
ito cells space of Disse
storage of vit. A
blood flow portal vein %75
hepatic artery %25 blood flow
supply hepatic artery %50 supply

liver function test


Liver fuction test serum
albumin Prothrombin time synthesitic
function of the liver Investigation
liver compensating or decompensated
serum albumin prothrombin time investigation
serum billrubin chronic liver
disease

chronic liver disease cirrhosis hepatitis
liver compensated or not
15


..............................................................
serum prothrombin time serum albumin
billrubin
half life albumin
serum albumin negatively half life
sever chronic liver disease
chronicity + severity

acute liver serum albumin


disease
usually
Liver compensated
or not
prothrombin time prothrombin time
acute liver very short half life
disease
viral hepatitis acute viral hepatitis
compensated or decompensated Liver
serum albmin prothrombin time
prolonged with prothrombin time
differniate biliary obstruction cholestasis
prolonged prothrombin time between
decompensation cholestasis
prothrombin time assesment vit.k injection
vit.K injection prothrombin time assesment
prothrombin time prolonged
decompensation
bile obstructive jaundice
cholestasis vit.K absorption
vit.K injection prothrombin time prolonged
prothrombin time
16


..............................................................
decompensated

hepato cellular
damage liver
liver
virus B virus C drugs cupper

trans amines hepato cellular


damage
wt about the liver compensated or not
synthestic function Liver albumin
prothrombin time

chronic liver disease decompensated


albumin prothrombin time prolonged
SGPT ALT more specific more
sensitive hepatic damage
SGPT & SGOT
tissues rise
once SGPT high hepato cellular damage
SGOT hepato cellular damage
myocardial infraction short half life
acute hepatitis
SGPT
examples liver cirrhosis trans
amines normal mild elevation chronic

17


..............................................................
sever mild elevation mild form hepatitis
form

liver enzymes acute hepatitis


acute viral hepatitis 700

function state of the liver Alkaline phosphatase

liver alkaline phosphatase


cholestasis
cholestasis
significant biliary obstruction cholestasis
stone in common bile duct cholestasis
cancer pancreas stricture extra hepatic
alkaline phosphatase
acute or chronic viral hepatitis
element of swelling of hepatocyte
intarhepatic biliary bile canaliculi narrowing
alkaline mild biliary obstrcution obstrcution
phosphatase mildy

alkaline phosphatase
acute viral hepatitis

significant biliary
mechanical obstruction

extra stricture cancer pancreas


hepatic biliary obstruction

18


..............................................................
cholestasis direct
billirubin bile salts retain in blood
alkaline phosphatase direct billirubin

alkaline phosphatase bile salt retention


in blood

alkaline phosphatase
liver alkaline phosphatase abmic liver
abscess Alkaline phophatase liver
alkaline phosphatase
alkaline phosphatase Liver bone
Intestine Placenta
alkaline phosphatase
Liver Gamma GT elevated
alkaline phosphatase elevated hepatic disorder
or biliary obstruction

gamma GT
gamma GT hepato cellular
damage alcoholic
hepatitis gamma GT enzyme inducer
gamma GT
alcoholic hepatitis gamma GT

gamma Gt liver
19


..............................................................
alkaline phosphatase cholestasis
more sensitive cholestasis
gamma GT more sensitive
very mild biliary obstruction
alkaline phosphatase gamma GT


alkaline phosphatase trans amines
alkaline phosphatase trans amines
liver
trans amines hepatitis
biliary alkaline phosphatase mild elevaltion
alkaline phosphatase markdly obstruction
trans amines elevated
retention of billirbin biliary obstruction
contact with hepato cyte bile inside the liver
hepatocytes irritation bile retention
trans amines
alkaline phosphatase trans amines
trans amines

blie Liver cholesterol


bile retention biliary obstruction
liver
bile vascular Liver
blood bile salts billirubin blood
cholesterol

biliary hyper cholestrolemia

20


..............................................................
obstruction

liver biliary obstruction hyper
lipidemia hyper cholesterolemial primary biliary
cirrhosis

total plasma protien albumin




albumin
normal
total plasm protein high


chronic liver disease
chronic liver disease cells
reticulo endothelial system liver
phagocytosis organisms antigens blood
reticulo endothelial system
hyperplasia excessive production of
gamma globulin
blood
gamma pathies multiple myeloma
problems multiple myeloma

old male bony ache ESR total plasma
protein
multiple myeloma
21


..............................................................
gamma globulin high total plasma protein

chronic liver disease



alcolic liver IgA alcoholic liver disease
peripheral blood unable to remove IgA disease
serum IgA uptake Liver
GIT IgA execretion in bile
IgG
primary biliary cirrhosis IgM
unconjugated hyper billirubin
unconjugated billirubin billirubinemia
unconjugated total billirubin %80
hemolysis billirubin

hemolysis

Low hemoglubin 2- high indriect billirubin 3- high -1
reticulocytic count
hemolysis
syndrome suspect

conjugation conjugated billirubinemia

hepato cellular failure biliary obstruction
prothrombin time prolonged
Liver low serum albumin
hepato cellular failure decompensated
22


..............................................................
direct billirubin alkaline phosphatase
gamma GT liver compensated
prothrombin time serum albumin
biliary obstruction

jaundice hepato cellular


obstructive investigation
alkaline phosphatase Gamma GT obstruction
prothrombin time prolonged hypo
albuminemia liver cell failure

behavior serum bilirubin acute


liver disease bilirubin cholestasis
bilirubin acute hepatitis cholestasis
hepatocyte subside
swelling bilirubin
chronic liver disease liver cirrhosis
bilirubin bad sign
decompensated liver

tumor marker alpha feto ptn


) hepatocellular carcinoma
(

alpha feto ptn hepatitis


cirrhosis
hepatoma

23


..............................................................
marker Des-y-carbaxy
prothrombin metabolite malignant liver
more specific alpha feto ptn
alpha feto ptn sensitive
hepatoma alpha feto ptn
Bromsulphthalein(BSP)clearance test
Dubin Johnson syndrome
Bromsulphthalein dye Liver
dye
Uptake excretion dye
Bromsulphthalein dye
blood liver uptake
excretion
defect secretion dye
retention in liver Liver uptake dye
excrete dye dye .
Dubin Johnson syndrome

sonar Liver size Pattern


Lesion cirrhosis


Intrahepatic biliary dilatation extra
hepatic biliary obstruction common bile
duct
investigation common bile duct
ERCP (Endoscopic Retrograde Cholangio
(Pancreatography
common bile duct
24


..............................................................

jaundice obstructive direct
bilirubin alkaline phosphatase Gamma
GT

obstructive jaundice
abdominal sonar Intrahepatic biliary
dilatation common bile duct
investigation ERCP
ERCP infection pancreatitis
prophylactic esophagus
stomach duodenal canulation ampulla of vater
dye common bile duct dye
pancreatic duct pancreatic duct common
bile duct

liver biopsy

hepatomegaly Persistent
elevation of trans aminases
elevation of trans aminases

viral marker HBsAg HA
antibody HC antibody

marker

auto immune marker ANA


cupper and iron prolife

25


..............................................................
high level of transaminases
hepato cellular damage
damage viral auto immune cupper iron
overload
history of any medication
hepto toxic
approach


follow up

.
persistent elevated indication
of liver biopsy

viral marker
auto immune marker cupper profile iron
profile anesthesia
hepatic
support
Liver
biopsy unexplained persistent elevation of
liver enzymes

focal lesions liver Indication of liver biopsy


hepatoma hepatoma biopsy
biopsy More dissemination seeding

26


..............................................................
liver biopsy Precaution
prothrombin time platelets
methods of liver biopsy bleeding tendency
trucut or Menghini needle through an intercostal
space, in mid axillary line during expiration using local
analgesia

bleeding injury complication


liver hemobilia
infection common bile duct
bleeding tendency contra indication
focal lesion hepatoma
focal lesion in sonar
Malignant benign
( radio isotopes ) liver
liver intra venous technetium-99m
radio Gamma camera uptake
activity of the liver
liver cirrhosis Liver
liver diffuse
reticulo endothelial system Liver cirrhosis

reticulo endothelial system
uptake technetium-99m Liver cirrhosis
Liver reticulo endothelial system of the liver
diffuse low uptake cirrhosis
focal lesion hepatoma hepatoma
reticulo endothelial system Liver
focal low uptake
27


..............................................................

Liver diffuse low


uptake cirrhosis
Liver focal area
Low uptake suggest hepatoma
virus c alpha feto ptn

CT scan MRI focal


lesion liver focal lesion benign or
malignant
focal lesion Liver

focal lesion liver
focal lesion
CT scan MRI benign
malignant
alpha feto ptn

laparoscopy
peritoneal disease peritoneum T.B.
peritonitis mesothelioma peritoneum
malignant deposit peritoneum cancer
ovary malignant deposition in peritoneum
peritoneum laparoscope
biopsy lesion

Acute Hepatitis
Hepatitis Inflammation of liver parenchyma
Acute
28


..............................................................
viral A,B,C
hepato tropic virus EBV Herpes CMV Non
hepato tropic viruses
Liver Liver
virus A RNA virus picorna=entero virus
incubation period feco oral
fulmination

malignancy chronicity carrier
acute hepatitis
cholestasis cholestasis A
cholestasis
!!! cirrhosis
cirrhosis
marker virus A antibody
antibody of the virus Ig M recent
infection Ig G old infection

vaccine inactivated virus


vaccine
booster dose 12
vaccine

vaccine
fulminant hepatitis

29


..............................................................
protection
Mainly endemic areas

Immune globulin Gamma globulin


recent exposure
Hepatitis A
infection Immune
globulin valid

Perfect
endemic
Gamma globulin vaccine

B incubation period A
malignancy chronicity
50
chronic hepatitis of C rule
acute hepatitis chronic
ve in blood+ chronic hepatitis
rule 5 acute viral
hepatitis B
fulmination carrier
carrier completely healthy carrier
normal normal surface antigen
positive
Immune response
resolution Virus A&B are not directly
cytopathic
30


..............................................................
Liver
immune reaction immune
system resolution

resolution immune system
Liver
Immune response hepatitis pathology
viral hepatitis B Invasion viral liver
Immune reaction Liver
Immune reaction immune system
hepatitis Immune
system clearance
resolution good immune response
Hepatitis

resolution

carrier immune system


immune system interested
immune system

!!!
clearance

chronic Hepatitis
Immune system Immune system
in-competent
hepatitis chronic
clearance

resolution
chronic carrier degree
31


..............................................................
immune response Immune system clearance

marker )
(
surface antigen DNA core antigen DNA
polymerase surface antigen core
core DNA & DNA polymerase
marker Hepatitis B surface antigen
positive viral hepatitis infection

acute viral hepatitis B surface antigen


positive positive
surface antigen clearance
surface antigen ...
chronic carrier
liver enzymes
biopsy biopsy hepatocyte
almost within normal carrier chronic
manifestations

surface antigen positive


transaminases acute viral hepatitis B
surface antigen
viremia surface antigen
transaminases

surface antibody Immune


system surface antibody

32


..............................................................

infection vaccine

vaccine
surface antigen genetically engineered
surface antibody

surface antibody positive immune


Hepatitis A antibody
Hepatitis C antibody Hepatitis B antibody
Hepatitis C antibody positive
Hepatitis C antibody positive
virus C Immune system
Immune
Hepatitis B surface antibody Positive
Immune
anti-body effective release surface
antibody Hepatitis B

core anti gen


hepatocyte hepatocyte
Inject core hepatocyte core antigen
core antibody Ig
M & Ig G

window gap
core anti body Ig M
Infection

33


..............................................................
surface antigen negative
surface antibody negative
core antibody Ig M positive
window gap
core antibody Ig G core
antibody Ig M
core antibody Ig M recent infection of
virus B
recent infection viral B
marker markers
surface antigen surface antigen Positive
positive
... positive positive
surface antibody positive
core antibody Ig M
core antibody Ig M positive
recent infection core antibody Ig G positive
Old infection
acute Hepatitis B infection correlated
core antibody Ig M
chronic infection Past infection
core antibody Ig G

e Antigen
active active e Antigen
Hepatitis B DNA PCR


34


..............................................................
chronic hepatitis
surface antigen core antibody Ig G
surface antigen positive
Hepatitis B infection
Infection acute core
antibody Ig G Infection e' long duration
core antibody Ig G positive
positive late surface antigen cleared
surface antigen positive core antibody Ig G
positive persistent elevated Hepatitis B surface
antigen chronic carrier

carrier marker almost chronic
hepatitis markers Presentation
transaminases pathology
biopsy

Prophylaxis
vaccine vaccine 6-1-0
vaccine
vaccine surface antigen
blood transfusion
hemodialysis
hemodialysis immune system
vaccine double the dose in
immune compromised patients
chronic renal failure

dose 6-1-0

35


..............................................................

sexual intercourse
PCR negative low
viremia transmission
RNA


vaccine
carrier

HIV

vaccine 0-1-6

HBIG Hepatitis immunoglobulin


recent exposure
It should be given within 24 hours or at most a week from exposure to infected
.blood

C antibody
C antibody Positive ELISA RIBA
infection with virus C
liver active or not
PCR is mandatory PCR
Quantitative active
chronicity % 50 malignancy
carrier
36


..............................................................
sexual transmission
E A fulmination
) ( Hepatitis D virus B
core coat B
pathogenic virus
Co-infection super infection
*** Co-infection B Delta
dangerous fulmination
*** super infection virus B infection
delta
super infection
for example Hepatitis B chronic
mild form delta super infection sever
form
co-infection fulmination
clinical pathology

co-infection super infection


co-infection Markers Ig M recent
delta antibody Ig M recent
Core antibody Ig M
*** Ig M
super infection marker
core anti body B
Ig G delta antibody Ig M

37


..............................................................
acute viral hepatitis portal tract
Inflammatory cells hepatocyte swelling
narrowing .(centizonal necrosis (zone 3
centizonal necrosis
acute
non icteric icteric non icteric bilirubin
common

acute virus C
A B C
usually
non icteric bilirubin 2.5
jaundice
flu like
bone ache
viremia viremia viral
hepatitis infectious mononucleosis CMV


anorexia
viral hepatitis
SGPT
acute
chronic cirrhosis cirrhosis
retro grade

Non icteric A
bone marrow bone marrow
aplasia manifested e' anemia
38


..............................................................

Investigation viral hepatitis
manifestation viral hepatitis feverish
bone marrow aplasia

The commonest cause of bone marrow aplasia viral
infection
bone marrow aplasia
transient
icteric pre icteric

viremia fever Headache malaise
liver liver swelling Inflammed
cholestasis jaundice
hepatocellular jaundice cholestatic jaundice
jaundice cholestasis
hepatocellular jaundice
dark urine clay stool
dark urine clay stool
( dark urine(bilirubinuria direct bilirubin
clay stool bilirubin cholestasis
intestine direct bilirubin Intestine
stercobilin
jaundice
fever subside
causes of fever jaundice
viral hepatitis
fever jaundice fever and jaundice

39


..............................................................
general jaundice fever
( )

tender liver is enlarged On examination


RES hyper plasia spleen soft
spleen just on examination fever
possibilities palpable
echo & blood culture endocarditis ***
small tarns esophageal echo
vegetation
Viral hepatitis***
Transaminases & viral marker
brucella agglutination test brucella ***
paul panel test mononucleosis ***
test
EBV antibody test mono spot test test
Ig G and Ig M
widal test ***

differential diagnosis of fever with


splenomegaly
differential diagnosis of fever with just palpable
spleen
paragraph
investigation clinical manifestation
differential diagnosis

40


..............................................................
management of a case of fever and just
palpable spleen
clinical picture
investigation treatment
management diagnosis treatment

differential diagnosis clinical picture


investigation
typical infective
endocarditis

post icteric

SGOT SGPT
SGOT short life span


acute hepatitis A is less severe than acute hepatitis
,B MCQ
cholestasis
A
B more severe serum sickness like
arthalagia vasculitis complication

C acute pass un noticed

41


..............................................................
complication viral hepatitis
acute chronic chronic cirrhosis acute
fulminant
signs of fulmination
hepatic encephalopathy prothrombin
time prolonged
cholestasis relapse post hepatitis syndrome

Liver Liver
Liver symptoms

hepatoma very bad sequel



viral hepatitis
unconjugated bilirubin

extra hepatic manifestation problem solving


aplastic anemia
viral hepatitis bone marrow aplasia
viral hepatitis arthritis
Cryoglobulinemia hepatitis C
immune complex glomerulonephritis B
& C C
) ( hepatitis C
cryoglobulin antibody in vitro very
active very low temperature
cryoglobulin antibody virus C
cryoglobulin vasculitis
glomerulonephritis provoke immune reaction
42


..............................................................
C glomerulonephritis
cryoglobulin
) (
C
C positive cryoglobulin
glomerulonephritis
!!!
+
C urine analysis
proteinuria investigation
cryoglobulin in blood C
cryoglobulin cryoglobulin
glomerulonephritis
steroid

immune complex vasculitis


vascultitis poly arteritis nodosa
Hepatitis B infection C
MCQ poly arteritis nodosa
positive hepatitis B surface antigen

investigation bilirubin transaminases


transaminases markedly elevated serum
bilirubin normal alkaline phosphatase
mild elevation parenchyma
cholestasis

43


..............................................................
prothrombin time normal prothrombin
time acute hepatitis bad prognosis
fulmination

non specific
diet fat
common
mistake common acute viral
hepatitis

acute viral hepatitis hepatocyte liver
decompensated
restriction hepatic encephalopathy
liver cirrhosis Liver compensated

liver cirrhosis Liver decompensated


decompensated ascites albumin
prothrombin time
hepatic encephalopathy
once encephalopathy restriction


malnutrition Immune deficiency Infection

hepatitis G
C carrier fulmination acute
chronic

44


..............................................................
chronic hepatitis inflammation Liver
chronic liver disease chronic hepatitis
cirrhosis
B& C
alpha methyl dopa auto immune hepatitis
auto immune hemolytic anemia

Wilson hepatitis
cupper irritant Liver episodes of
hepatitis chronic cirrhosis

mild form of chronic hepatitis


portal tract mild inflammation in
hepatic lobule Liver architecture
activity sever form of
hepatitis
accidently
preoperative investigation mild elevation
transaminases
elevation of transaminases

viral marker auto immune marker cupper
iron profile medication
marker biopsy
mild form chronic hepatitis
retrograde viral C Viral B
idiopathic
follow up
biopsy mild from chronic
hepatitis
45


..............................................................
No need for interference
reassurance avoid hepato toxic drugs
hepatic support Silymarin
anti-oxidants


Mild form sever form

B delta super infection

sever form
biopsy
inflammatory cells Portal tract
Inflammatory cells central vein Liver
bridging necrosis piece meal
necrosis
bridging necrosis inflammatory cells
portal tract central vein
piece meal necrosis Liver parenchyma

signs of activity in sever form

biopsy
piece meal bridging
rosette appearance liver
cirrhosis
clinical picture hepatitis chronicity
jaundice malaise liver
46


..............................................................
tender enlarged
cirrhosis

extra chronic viral hepatitis auto immune


hepatic manifestation
chronic extra hepatic Acute
chronic long standing chronic chronic
viral c
extra hepatic manifestation of chronic viral
chronic arthopathy infection
cryoglobulin glomerulonephritis
glomerulonephritis C
membrane proliferative
commonest glomerulonephritis in Egypt is
C membrane proliferative
blood C
renal biopsy cryoglobulin
membrane proliferative

membranous glomerulonephritis hepatitis B

extra hepatic manifestation


Hashimoto's thyroiditis polyarthritis auto immune
Grave's disease auto hemolytic anemia
problem solving
auto immune female
Problem ::: female 40 yrs e' enlarged liver enzymes
,elevated
thyroid arthropthay

47


..............................................................

thyroid auto immune Liver


auto immune

written auto immune hepatitis


***** lupoid hepatitis ANA positive
antismooth muscle Ab
****** positive LKM ( Liver, Kidney, microsomal
common
(Ab
) ) soluble liver antigen +ve SLA

lupoid ANA


=ANA
=LKM
=SLA
markers chronic hepatitis
acute hepatitis
investigations
CBC
..... SGPT
A ,B,C ANA antisoomth muscle LKM
LKM positive auto immune type 2

48


..............................................................



dose 30 60
reduction dose
maintenance
clinical biochemical check up
full remission maintenance
remission


osteoporosis
myopathy hyper tension diabetes mellitus
auto immune disease

gradual withdrawal low dose
maintenance remission

SGPT
SGPT .....

49


..............................................................

azathioprine

)
(


) azathioprine (
cyclophosphamide
Lupus

reduction of the dose of
steroid azathioprine
methotrexate
rheumatoid
cyclophosphamide
hepatitis hepatitis B hepatitis C
hepatitis B conventional Interferon
every other day hepatitis B weeks 16
hepatitis C
conventional Interferon almost

pegylated interferon
pegasys one ampule 180

Ribavirin

50


..............................................................
indication interferon
hepatitis B replicating HB e Ag
positive DNA polymerase enzyme positive
DNA positive PCR
biopsy activity
activity
piece meal bridging

biopsy
other transaminases
high transaminases viral marker
Positive viral replication
biopsy

hepatitis C positive PCR biopsy high


transaminases transaminases
PCR positive high viremia



biopsy
side effects flu like
arthralgia depression neuropathy bone
marrow depression

51


..............................................................

chronicity

investigations
PCR Liver enzymes
PCR
negative
variable


flu like , arthralgia , fever
paracetamol responding

Ribavirin combination
hepatitis C

lamivudine antiviral
lamivudine oral

bilharziasis peri portal fibrosis no hepatic


loss of architecture cirrhosis

52


..............................................................
bilharziasis liver cirrhosis
bilhazia


hepatitis
pure bilharziasis fibrosis cirrhosis

pure bilharzial liver Liver


decompensated early Late
so late Peri portal fibrosis
portal hypertension
endemic bilharzial mixed with post hepatic cirrhosis

Liver cirrhosis Portal hypertension liver cell failure
bilharzial pure portal hyper tension liver
cell failure so late

hepato toxic drugs


acute hepatitis halothane INH
chronic hepatitis alpha methyl dopa INH
cholestasis
fatty liver Na valproate anti-epileptic
fatty liver

hepatic peliosis Peliosis hepatis androgen


anabolic steroid
53


..............................................................

hepatic necrosis fulmination


paracetamol toxicity
Budd chiari Contraceptive pills
female contraceptive pills
Liver
contra captive pills
cholestasis Budd chiari adenoma
female under contra captive pills liver

hepatoma Danazol

idiosyncrasy Halothane
hepatitis
idiosyncrasy
medication metabolite metabolite

hyper sensitivity hyper sensitivity


provoke type one hyper
sensitivity anaphylaxis urticaria broncho
spasm idiosyncrasy
metabolite

Post-operative jaundice Problem


jaundice
Halothane hepatotoxic drugs
accidently ligation of common bile duct

54


..............................................................
spontaneous bacterial peritonitis SBP

tapping ascites ascites


spontaneous peritonitis Infection
Liver cirrhosis spontaneous bacterial peritonitis
blood born infection ascites
lymphatic blood infection
peritoneal cavity Peritoneum organism
liver peritonitis
ascites cirrhosis
fever ascites liver cirrhosis
spontaneous diagnosis hepatic encephalopathy
bacterial peritonitis
gram gram staining
positive staining
fluid WBCs count
neutrophils 500 total leucocytic count
3rd generation SBP 250 poly morph
cephalosporin
portal portal vein thrombosis
blood disease polythythemia vein
pancreatic tumors
portal pyemia infection umbilicus
bacteremia bacteremia bacteremia
umbilical phlebitis portal vein
operation sepsis

portal hyper tension Portal vein


ascites
hypo portal hypertension ascites
albuminemia
55


..............................................................

acute sever portal portal vein thrombosis


ascites hyper tension
Proto systemic shunt collateral
absorbed ascites portal pressure subside

ascites Portal vein thrombosis


transient ascites

Problem Budd chiari


contra captive pills
female female under contra captive pills
enlarged Liver Pain in Rt hypo chondrium
Budd chiari
polythythemia Budd chiari
paroxysmal nocturnal common
hemolytic anemia hemoglobuinuria
vascular occlusion
Liver enlarged and Budd chiari syndrome
negative hepato jugular reflux tender

Liver portal vein abdomen
blood to inferior vena Hepatic vein Liver
hepato right side of the heart cava
abdmonial compression jugular reflux
Portal vein to the liver squeeze
right side of the heart hepatic vein Liver
hepato jugular reflux hepatic vein
negative

56


..............................................................
contra captive Budd chiari syndrome
positive tender liver enlarged pills
negative hepato jugular reflux

written
Enlarged tender liver
pain in the right hypo chondrium common
tender Liver enlarged examination
differential diagnosis
right side Budd chiari syndrome Hepatitis
abemic liver hepatoma failure

Budd chiari veno occlusive disease


central vein occulsion

liver Liver transplantation


split living donor cadaver
Left lobe liver transplantation
biliary atresia indications
wilson's disease
hepato cellular carcinoma
Liver transplantation hepatoma

infection metastasis contra indication


57


..............................................................
Liver kidney heart
brain Organ Organs
pre-operative donor receiver HLA
typing blood group cyclosporine
azathioprine prednisolone

Liver expensive
auxiliary liver transplantation
fulminant liver failure hope

liver normal Liver
auxiliary liver
Liver liver Left
lobe Liver liver function
fulminant liver failure
auxiliary liver Liver
chemo-therapy graft rejection

oral written sonar


Liver sonar focal lesion

focal lesion granuloma


focal lesions in liver
adenoma carcinoma hemangioma granuloma

focal lesion coin mass
Liver
focal lesion liver focal
lesion sonar MRI CT scan alpha
feto ptn
58


..............................................................
MRI CT scan benign malignant
hemangioma

granuloma liver
granuloma infection
tuberculosis leprosy syphilis Liver
hepato biliary disorder primary
biliary cirrhosis
primary biliary cirrhosis granuloma
Granuloma portal tract fibrosis
bile duct drugs allopurinol
hepatic cyst Echinococcus granulosus
cyst calcified in the liver CT scan
radiology liver calcified

Liver & pregnancy


hepatitis A B
Hepatitis B
+ HB Ig vaccine
hepatitis B + HB Ig vaccine

B virus fulmination

cholestasis of pregnancy cholestasis
swelling
hepatocyte
trimester Puritis benign condition
liver
pregnancy
59


..............................................................
HELLP syndrome HELLP syndrome pre-
eclampsia
H Hemolysis
EL Elevated Liver enzymes
LP Low Platelet count
HELLP syndrome Pre-eclampsia
delivery

Acute fatty liver of pregnancy


3rd trimester derlium
encephalopathy
encephalopathy
investigation
fulminant failure
fatal
hyperemesis gravidarum
) ( Liver enzymes

pregnancy in liver transplant recipient


Liver
graft immune
system Pregnant

child classification function state of the liver


child classification function
state of the liver

60


..............................................................
serum albumin serum bilirubin
Prothrombin time function state of
the liver liver cirrhosis
encephalopathy ascites
Mild A
moderate B
sever C
Liver cirrhosis albumin
bilirubin Prothrombin time

liver cirrhosis haemochromatosis


haemochromatosis written problem solving

haemochromatosis
haemochromatosis excessive iron
deposition in tissue
Liver
excessive absorption iron from intestine Primary
haemochromatosis defect small
intestine
excessive absorption of iron
autosomal recessive
iron absorbed tissues
male female female iron
overload menstruation

haemochromatosis

61


..............................................................
liver enlarged liver
cirrhosis enlarged liver shrunken
Liver cirrhosis long standing
liver shrunken haemochromatosis iron
overload iron infiltration
heart cardiomyopathy Problem
Heart failure
diabetes heart Liver
gonads normal iron deposition
pituitary gland hypo pituitarism
adult gonado trophins
hypo gonadism skin hyper pigmented
hyper pigmented skin skin sometimes
grayish in color grayish in color !!!
hyper pigmentation dark skin
diabetic 47 diabetic
nephropathy nephrotic syndrome
dyspnea orthopnea cardiac ischemic
heart disease heart failure





diabetic hepatic
liver enlarged heart failure right sided
Liver congested
grayish color hyper pigmentation
grayish color relatively
grayish

62


..............................................................
diabetes diabetic
hepatomegaly
type 2 fatty liver
type 1 glycogen infiltration liver
diabetes skin dark
item
Joints joints
Liver B C arthopathy lupoid
hepatitis arthopathy
viral hepatitis arthopathy Lupoid hepatitis
arthropathy Wilson Haemochromatosis
arthopathy
Investigation
iron iron binding capacity
Investigation iron overload transferrin saturation

200 biopsy biopsy


CT scan
pigmentation cirrhosis
haemochromatosis primary biliary
hyper pigmented
Iron
500 blood 250 Iron
adult iron

haemochromatosis
Iron 60

63


..............................................................
veno section

follow up Iron profile
anemic iron
stores release iron blood blood
RBCs iron iron
overload satisfactory result
veno section

haemochromatosis hepato cellular
carcinoma cardio myopathy
chelator ) ( desferrioxamine
( (desferal
haemochromatosis
hemosidrosis acquired common acquired
hemosidrosis chronic hemolytic anemia
thalassemia
hemolysis
RBCs iron
haptoglobin hemopexin
RES chronic hemolytic anemia definitely
Iron overload iron overload iron
RES organ parenchyma primary
haemochromatosis iron in organ parenchyma
more injurious than hemosidrosis
thalassemia liver function
thalassemia viral hepatitis
thalassemia cardio myopathy
thalassemia hypogonadism
haemochromatosis thalassemia iron
over load organ RES organ
organ parenchyma haemochromatosis
hemosidrosis
64


..............................................................
Wilson Wilson written Problem

Wilson Liver enlarged jaundice


involuntary movement
Liver cell failure
flapping tremors
liver enlarged
Involuntary movement Wilson

Parkinsonism
Liver cirrhosis
Liver cirrhosis
parkinsonism
examination
abdominal examination
abdomen neuro abdomen
general examination comment on heart
and chest and abdomen comment
systems
heart just auscultation heart sounds
additional sounds Murmurs Heart
Neck vein
abdomen
cardiology
auscultation
murmur !!! anemic

65


..............................................................
chest auscultation
crepitation
TVF Percussion chest

abdomen
liver, spleen and ascites
systems Part general
examination

Wilson cupper Wilson



cupper duodenum Liver
Liver ceruloplasmin cupper
cupper
cupper
Liver bile intestine stool
defect Wilson
in ability of the liver to excrete the cupper
cupper Liver bile Liver
liver

haemochromatosis intestine
Liver

66


..............................................................
cupper Liver
Haemochromatosis Liver transplantation
Wilson Liver
Wilson ceruloplasmin
liver Liver ceruloplasmin cupper
free
two abnormalities in Wilson liver to
excrete copper Liver copper
ceruloplasmin ) cupper spelling
( cupper
cornea scleral junction
Kayser Fleischer ring slit lamp basal
ganglia involuntary movement
Presentation
recurrent attack of hepatitis
recurrent hepatitis

) (

)
viral marker viral marker auto
immune marker negative
hepatocellular damage

iron profile cupper profile
(
involuntary movement
basal ganglia
diagnosis
Problem
Wilson cupper blood low urine
high cupper free in blood
67


..............................................................
ceruloplasmin tissues cupper
tissues free

cupper Low in blood and high in urine


ceruloplasmin Low
written discuss iron and cupper overload

iron overload iron cupper over load
MCQ cupper

haemochromatosis

glycosuria
diabetic Wilson
free cupper tubular injury glycosuria
tubular defect

cupper Low in blood and high in urine
ceruloplasmin Low
written discuss iron and cupper overload

iron overload iron cupper over load
MCQ cupper

68


..............................................................
haemochromatosis

glycosuria
diabetic Wilson
free cupper tubular injury glycosuria
tubular defect glycosuria urine post
gasterectomy
. Haemochromatosis
glycosuria urine
hemolysis Wilson very mild
chelator cupper
penicillamine penicillamine very toxic

zinc acetate
Liver transplantation
alcoholic liver disease
No.1 fatty liver fatty liver Mild .
fatty liver
heaviness in right hypo chondrium
Liver enlarged some-times tender
fatty liver neutral fat
Liver parenchyma without inflammatory process
NASH Nonalcoholic steato-
hepatitis

steatosis fatty liver hepatic


steatosis fatty liver

69


..............................................................
Liver parenchyma
inflammatory process
steato hepatitis NASH

fatty liver Mild


elevation
fatty liver can be diagnosed by sonar
liver is bright bright liver
Liver parenchyma organ parenchyma
sonar CT scan grayish fat

Alcoholic hepatitis
hepatitis investigation

alcoholic hepatitis
SGOT SGPT SGPT
suppressed deficiency
alcohol intake SGPT content
in the liver
liver SGOT SGPT

SGOT SGPT
scientific
scientific SGOT
SGPT sever hepato cellular damage
SGOT hepatocyte mitochondria
SGPT cytoplasm hepatocyte
SGOT release from mitochondria
70


..............................................................
SGOT more high SGPT

ratio alcohol

Gamma GT
High Ig A
biopsy Mallory's hyaline Mallory's
hyaline hyaline material hepatocyte
alcoholic liver disease
primary biliary cirrhosis
RBCs macrocytic macrocytic non megalo
blastic

::: alcoholic liver disease Non megalo blastic


macrocytosis
lipid blood
Lipid RBCs macrocytic
megalo blastic

-2 chronic liver disease macrocytosis


chronic liver disease
RBCs

RBCs chronic liver disease


chronic advanced liver disease RBCs
acanthocyte acanthocytosis
blood RBCs RBCs spikes
acanthocyte
71


..............................................................

alcoholic cirrhosis
alcoholic cirrhosis very
susceptible Hepato cellular carcinoma
cirrhosis hepatoma
post hepatitis cirrhosis hepatoma
B hepatoma hepatoma B
C C

haemochromatosis hepatoma
alcoholic cirrhosis hepatoma
primary biliary cirrhosis
cupper overload
Wilson
cupper protective for the liver
against hepatoma
cupper protective

haemochromatosis hepatoma Wilson


factors very liable to alcoholic


cirrhosis alcoholic liver disease dose duration
male female malnutrition
Hepatitis B surface antigen positive
viral hepatitis

. anti fibrogenesis
colchicine
72


..............................................................
fibrogenesis Liver
cirrhosis
good nutrition amino acids
specific alcoholic liver disease
complications of liver
cirrhosis portal hyper tension Portal hyper
tension rupture varcies
ascites hepatic encephalopathy Hepatoma

poor prognostic indicator in liver cirrhosis
child classification
Liver cirrhosis ascites
Lower limb edema Jaundice
bilirubin albumin Prothrombin
time encephalopathy

Problem
primary biliary cirrhosis
problem female itching
Itching female Hepatic lobule
Portal tract Inflammatory cells
inflammatory cells granuloma
granuloma chronic specific inflammation granuloma
fibrous tissue bile
fibrosis
duct ( cholestasis ( biliary obstruction
Obstruction Intra-hepatic hepatic lobule
Peripheries portal tract
cholestasis bile contact
hepatocyte bile irritate the hepatocyte and
73


..............................................................
provoke chemical inflammation liver
cirrhosis
manifestation itching jaundice
female 45 yrs itching On
examination Liver enlarged primary
biliary cirrhosis
fat soluble vitamins
bile intestine absorption K
bleeding tendency absorption D oesteo-
dystrophy hepatic oesteo-dystrophy
hepatic oesteo-dystrophy D
primary biliary cirrhosis
hyper lipidemia Primary biliary cirrhosis

Itching retention bile salts in blood
bile acids in blood central mechanism
opioid like
opioid
receptor Itching


!!! itching

) (

Naloxone Naloxone anti-dote
) (
liver
opioid receptors
central mechanism
simply bile salt retention mechanism
74


..............................................................


data
primary biliary cirrhosis differential
diagnosis Possibilities

one diagnosis One
diagnosis possibilities

One one

what is the most likely diagnosis


Most likely logic Logic
obstructive jaundice
Primary biliary cirrhosis renal failure
lymphoma

female Liver
primary biliary cirrhosis

primary biliary cirrhosis
liver spleen Lymphoma
female Liver spleen primary
biliary cirrhosis primary
biliary cirrhosis differential
diagnosis lymphoma
liver spleen
) (
anti-body specific Anti- mitochondrial anti-
body anti-body

75


..............................................................
auto Immune mediated liver disease
primary biliary cirrhosis immune hepatitis
diagnostic liver biopsy
Ursofalk Ursodeoxycholate
acute hepatitis cholestasis
Liver cirrhosis chronic hepatitis acute hepatitis
cholestasis
cholestasis mild
liver cirrhosis chronic hepatitis acute hepatitis
cholestasis

sever you can give Ursofalk


gall bladder Ursogall
clinical pictures Xanthelasma
Xanthoma Xanthelasma
Xanthoma Liver Lipid deposit
Xanthelasma
lipid deposit on eye lid Xanthelasma
creases palmer aspect erupted Xanthoma
fat buttocks some times on buttocks
deposit

Cholestyramine supplement Vit. K


bile salt in intestine chelator
entero hepatic circulation
effective
oesteo-
oesteoprosis oesteo malcia dystrophy
effective
other immune suppressive drugs
76


..............................................................
azathioprine cyclosporine Liver
transplantation

sclerosing cholangitis vanishing


duct syndrome

vanishing duct syndrome

primary biliary cirrhosis
vanishing duct duct liver

hepatic ducto penia



Primary biliary cirrhosis auto
immune arthopathy
liver
sclerosing cholangitis intra hepatic
extra hepatic obstructed
biliary cyst
Primary biliary cirrhosis sclerosing cholangitis
Male female ANCA
ANCA
ANCA positive granuloma , vasculitis

(Liver cell failure (LCF


Ascites hypo albuminemia portal hyper
tension
77


..............................................................
pulmonary
cardiovascular blood microcytic
hypochromic chronic blood loss
normocytic normochromic hypersplenism
macrocytic Macrocytic chronic
liver disease Non megaloblastic
advanced liver disease B12 liver folic
acid Liver ..... Liver
disease B12 or folic acid deficiency
megaloblastic anemia macrocytic non megaloblastic
deposit of fat RBCs
chronic liver disease fats Liver
RBCs cardio vascular system
vaso dilatation (nitric oxide (NO
(vaso active intestinal peptide (VIP hyper
dynamic circulation Pulse
hyper dynamic big pulse volume vaso
dilatation hypotensive bad
sign ) (
Liver cell failure bad sign
vaso dilatation


Pulmonary manifestations central
cyanosis
Opening of the intra pulmonary shunts intra
pulmonary shunts venous arterial
cyanosis
therapy
therapy
.N.B

78


..............................................................
Hypoxia( or cyanosis ) due to Fallot , eisenmenger's
opening of the intra pulmonary shunts
cyanosis hypoxia
Fallot eisenmenger's intra pulmonary shunts
mix venous blood and arterial blood
venous arterial No response to oxygen
therapy
venous arterial

hypoxia chest condition Usually


hypoxia chest

adult respiratory distress syndrome
therapy hypoxia
shunt venous
arterial advanced
chest disease
eisenmenger's syndrome
eisenmenger's central cyanosis shunt
chest

skin manifestation spider navei palmar
erythema
Terry's nail white nail nail bed
Marked opacity

Hepatic Encephalopathy problem written


neurological psychiatric manifestions
Liver liver cirrhosis with precipitating
factor
79


..............................................................
Pre coma and coma pre coma
reversal sleep rhythm foetor
hepaticus Asterixis flapping termors
dysarthia chorea
liver cell failure involuntary
movement Wilson
mechanism

hiccough liver
renal failure renal failure yawing
Liver disease

Grades of hepatic encephalopathy


grade zero subclinical decline of intellectual
functions

grade one apathy


grade two lethargy verbal stimuli
grade three stupor vigorous
stimuli
grade four coma coma respond early to
pain
80


..............................................................

early hepatic encephalopathy stage



constructional apraxia test
number connection test

flapping tremors
hepatic encephalopathy

Hepatic encephalopathy
..... .... ....
... metabolite metabolite ... Liver Liver
detoxification metabolite
Liver portal vein to bypass the liver
systemic circulation porto systemic shunt
Liver disease No1 metabolite
bypass portal hyper tension

toxins metabolites
agitation interfere with kerb's cycle
in brain utilization of
glucose
brain Interfere
utilization excited
hypoglycemic

Mercaptans false neurotransmitter


aromatic amino acids branched amino acids

81


..............................................................
false
neurotransmitter

problem hepatic encephalopathy


abnormal behavior excited
tremors history chronic
liver disease hepatic encephalopathy

precipitating factors Hepatic


encephalopathy liver cirrhosis
liver
GIT bleeding GIT bleeding
Problem consequences of GIT
bleeding Liver cirrhosis frank

shocked hepatic encephalopathy


diruetics hypo kalemia diruetics



high protein diet
Infection

accumulation of ascites

volume

electrolyte disturbances
diruetics
82


..............................................................

infusion
re accumulation
constipation
infection
spontaneous bacterial peritonitis
ascites

delirium
excited subdural
haematoma common in old age trivial trauma
trivial head injury

sub dural behavior
investigations
CT scan sub dural

hypo glycemia
alcohol withdrawal alcohol
withdrawal diazepam
Sub dural conservative treatment wait and see
hypo glycemia glucose injection

Hepatic encephalopathy diazepam

:::
83


..............................................................
Control precipitating factors
eradication of bacterial flora Neomycin
partially absorbed
nephron toxic control of
precipitating factors stop the diruetics injection
scelro therapy diruetics
Neomycin
3rd generation cephalosporin
injection spontaneous bacterial peritonitis
Infection
3rd generation cephalosporin
ciprofloxacin
enema
lactulose lactulose

diarrhea lactulose
dose stool
stool hard watery

diarrhea hypo volumia hypo kalemia


precipitate and aggregate the
encephalopathy L-dopa

recent trends in treatment of hepatic


encephalopathy
haemoperfusion
filter dialysis toxin

84


..............................................................
anti body hepatic encephalopathy
GABA hepatic encephalopathy
benzodiazpine symptoms diazepam
diazepam
GABA GABA receptor
GABA GABA receptor hyper sensitive
valium GABA receptor
flumazinel Anexate
viable hepatocyte
culture
transplantation
sedation MCQ
sedation sedation mandatory

encephalopathy

midazolam short acting benzodiazepine
flmazinel

Fulminant Hepatic failure acute


liver disease hepatic encephalopathy
originally normal
normal
Normal acute viral hepatitis
acute viral hepatitis hepatic
encephalopathy
fulminant liver failure written

85


..............................................................
acute liver failure fulminant
acute liver failure acute viral drugs
toxicity fatty
liver of pregnancy reye syndrome
feverish fever

rheumatic fever Kawasaki

Kawasaki far east
Kawasaki

viral infection chicken pox
influenza Para influenza
kawasaki
cervical lymph node
Investigation coronary vasculitis
myocardial infraction
Kawasaki
very rare

fulminant failure hepatic encephalopathy


encephalopathy
hepatic encephalopathy acute
hepatic encephalopathy precipitating factor
hepatic encephalopathy liver cirrhosis
precipitating factors
acute encephalopathy fulminant failure

86


..............................................................
clinical pictures encephalopathy
Investigation bilirubin
prothrombin time albumin
sonar liver
3 sonar
Radio isotope scan Liver no uptake
at all Liver Necrosis
liver regenerate
encephalopathy hypo
kalemia hypo natremia hypo glycemia bleeding
tendency brain edema brain edema
with low papilledema space occupying
lesion
brain edema papilledema
waste products brain capillaries
damage blood brain barrier edema
brain edema papilledema
papilledema Increased intra cranial
tension brain edema papilledema

lactic acidosis

liver Liver transplantation
fulminant failure

auxiliary liver
liver auxiliary liver

87


..............................................................
causes of ascites in absence of intra Ascites
( hepatic liver disease ( intrinsic liver disease
Liver disease
Non hepatic causes of ascites
right side failure congestive heart failure
peritoneal disease
nephrotic syndrome
malignant deposit .T.B mesothelioma
lymphatic lymph node cancer ovary
acute pancreatitis mexedema obstruction
Liver Budd chiari Budd chiari
vascular disease
Important causes
Lower limb ascites
Local edema
) ( Problem solving
lower limb edema ascites
local disease Local disease
malignant mesothelioma peritonitis
Malignancy in peritoneum
ascites precox
constrictive pericarditis
diuretics Liver cirrhosis
Portal hyper tension Localization
right sided pleural ascites
peritoneum natural channel effusion
pleura
Meig's syndrome Meig's syndrome
fibroma ovarian tumor ovarian tumor
ovarian tumor syndrome
right sided pleural effusion ascites
Meig's syndrome
88


..............................................................

ascites investigations
Liver functions
Laparoscopy local cause
peritoneal carcinoma Malignant deposit
exudate transudate
albumin peritoneal fluid
albumin gradient albumin
gradient Level of ascetic albumin and
plasma albumin
) Liver cirrhosis (
advanced serum albumin 2
Malignancy ) (
transudate exudate

tansudate Liver cirrhosis heart failure
nephrotic syndrome generalized edema
peritoneum transudation
exudate Inflammatory malignant
albumin level ascetic fluid
albumin level ascetic fluid 3
exudate
Liver cirrhosis serum
albumin malignant ascites
malignant ascetic fluid serum
!!
exudate transudate ascetic
albumin plasma albumin
albumin gradient differences plasma
albumin and ascetic albumin

89


..............................................................
Differential diagnosis of cirrhotic ascites

differential
diagnosis of ascites
management of ascites
definition etiology ascites
cirrhosis
malignant ascites
mexedema
constrictive pericarditis
ascites ascites
liver cirrhosis right sided heart
failure pancreatitis

Treatment of Ascites rest salt restriction


fluid restriction
diuretics spironolactone spironolactone
gynecomastia very painful gynecomastia
tender
spironolactone Lasix otherwise
diuretics Lasix

sessions

albumin infusion


replacement of albumin re accumulation
criteria safe paracentesis
90


..............................................................
systems

ascites
criteria criteria


criteria system
tense lower limb edema
ascites Lower limb edema

edema
ascites tense
file
Lower limb edema ascites moderate
ascites

Serum bilirubin Platelets

serum creatinine otherwise


hepato renal failure session

ascites refractory Salt retention
hypoalbuminemia salt restriction
diuretic
91


..............................................................
diuretics diuretics

Na excretion water
Low salt syndrome diuretics
fluid restriction
diuretics

T.B. peritonitis malignant ascites

line Le veen shunt ultrafiltration Le


veen shunt jugular vein
peritoneum
TIPSS
TIPSS ascites relieve
portal hyper tension TIPSS
ascites Liver decompensated

TIPSS contra indicated


TIPSS encephalopathy TIPSS
relieve portal hyper tension
liver transplantation

Refractory ascites written


refractory ascites
cirrhotic ascites Ascites mexedema
constrictive pericarditis nephrotic

refractory ascites diuretic resistance
fluid restriction salt restriction
92


..............................................................
160 lasix 400 full dose spironolactone
refractory
diuretic resistance
diuretics
Ultrafiltration Le veen shunt albumin infusion
TIPSS & reinfusion
transplantation

ascites Intractable ascites


encephalopathy diuretics
diuretics
liver transplantation encephalopathy
refractory diuretic resistance

portal hyper tension


presinusoidal
Periportal fibrosis
Portal vein thrombosis
sarcoidosis
MCQ Congenital hepatic fibrosis
presinusoidal portal hypertension

presinusoidal portal hypertension cirrhosis


granuloma in portal primary biliary cirrhosis
tract

sinusoidal portal hyper tension


93


..............................................................
Liver cirrhosis

post sinusoidal
( hepatic vein occlusion (Budd Chiari syndrome
Central vein occlusion (veno-occlusive & alcoholic liver
(disease
Portal humoral material
enothelin hypertension
vaso constrictor
systemic vaso dilatation
stimulation Nitric oxide circulation
rennin angiotensin aldosterone system
Portal hyper tension

complication portal hyper tension


complication of portal hypertension
Hyper splenism rupture varices
renal renal failure pan cyto penia
toxins rupture varices failure
portal hyper tension bypass the liver
renal failure shocked rupture varices
acute tubular necrosis
Hepatic Hepatic encephalopathy ascites
( porto systemic encephalopathy) encephalopathy
Portal hyper tension
metabolite ... ...
bypass portal hypertension ... portal vein
systemic circulation the liver
three
types of hepatic encephalopathy

94


..............................................................
liver cirrhosis
precipitating factors infection
fulminant failure Hepatic encephalopathy
acute without precipitating factors
chronic porto systemic shunt written
hepatic encephalopathy
hepatic encephalopathy

Problem solving
Liver hematemesis
hematemesis hepatic rupture
varices peptic ulcer
Liable peptic ulcers gastrin
hormone Metabolized in liver advanced
liver disease gastrin
peptic ulcer


presentations rupture varices peptic
ulcer hematemesis
peptic ulcer most painful hematemesis

peptic ulcer
painless

profuse bleeding
rupture varices

95


..............................................................

shock encephalopathy Portal hypertension
pitressin systemic vaso constriction
terlipressin octreotide octreotide
stomatostan MCQ
rupture
vaso constriction

mesenteric arteriole intestine vaso


constricted blood flow intestine
venous drainage Intestine Portal vein
portal pressure low vaso constrictor
portal vein vaso constrictor mesenteric
arteriole indral indral
prophylaxis
indral Prophylaxis large dose
cardiac out put Liver cirrhotic
ischemic
tachy cardia tachy cardia
B blocker

injection sclerotherapy
sclerosing material bucrylate
histoacryl

Sanfgestaken or Minnesota tube momentary
transient
best treatment rupture varices injection
sclerotherapy

96


..............................................................
k
Sangstaken or Minnesota tube

portosystemic shunt TIPSS


TIPSS internal jugular vein
superior vena cava right atrium
inferior vena cava hepatic vein
stent hepatic vein portal vein tributary

portosystemic shunt portal vein heptic
vein encephalopathy theoretically
Portal vein toxins hepatic vein
branch tributary portal vein portal
vein hepatic vein
Liver cell failure Liver decompensated
decompensated TIPSS
portal hyper tension liver
transplantation

acute attack
sclerotherapy
banding in acute attack Ligation
TIPSS
In between attack
prophylaxis of hematemesis
rupture varices banding
injection sclerotherpay TIPSS
portal hypertension attack

97


..............................................................
pitressin terlipressin octreotide somatostan

portal pressure attack B
blocker
tumors benign tumors liver
adenoma hemangioma benign tumor in liver
hemangioma
sonar CT scan

hepatoma hepatitis B Hepatitis


C haemochromatosis
Wilson common

clinical pictures liver cirrhosis


Liver cirrhosis ascites
jaundice


aggravating factors
diuretics Infection
sonar normal
focal lesion in liver alpha feto protein CT
scan MRI hepatoma

para malignant syndrome hepatoma


erythropoietin like polycythemia insulin like
material hypo glycaemia para thyroid
hepatoma written problem solving

98


..............................................................
insulin like material hypo glycaemia
excessive consumption of malignant cells
glucose
alpha feto protein investigation
benign focal lesion Liver
spiral CT scan MRI malignant

local area with hepatoma liver scan


biopsy low uptake
hepatoma

Embolization
artery
gel foam hepatoma
liver Localized surgical resection
partial Localized Liver compensated
hepatoectomy

Recent non-surgical treatment of hepato cellular


carcinoma
radio frequency Injection
tumors of the liver Localized
Malignant benign
fibrolamellar carcinoma Secondary , primary

fibrolamellar
marker B hepatitis C
better prognosis than hepatoma

99


..............................................................
differential diagnosis of focal Hepatic nodule
lesion in the liver
differential diagnosis of mass in the liver
Causes
1. Nodular hyperplasia.
2.Adenoma.
3. Haemangioma.
4. Hepatoma.
5. Fibrolamellar carcinoma.
6. Abscess either pyogenic or amoebic.
7. Granulomas (see later).
Nodular regenerative hyperplasia
Small hepatocyte nodules unassociated with fibrosis. It is
associated with many
conditions such as connective tissue diseases, blood
diseases, & steroids therapy,
the condition usually presents as an abdominal mass,
liver biopsy is diagnostic.
Prognosis is good but hepatocellular carcinoma may
occur.
Focal nodular hyperplasia
It is a subcapsular liver nodule with central fibrosis. It is
almost always asymptomatic
( Fatty liver (Hepatic steatosis
macrovesicular microvesicular
diabetes obesity macro
diabetes diabetes type 2
type one fatty liver diabetes type 2 liver

obese diabetes type 2 Liver
fatty liver hyper lipidemic
glycogen liver infiltration type one diabtes
glycogen storage disease

100


..............................................................
microvesicular fatty liver of
pregnancy Reye's syndrome tetracycline toxicity
microcvesicular fulminant failure
lipotropic drugs : choline
restriction fat
NASH Non alcoholic steato hepatitis
fatty liver hepatic
steatosis fatty changes fatty changes
Liver hepatocyte inflamed
steato hepatitis NASH
liver cirrhosis

Item jaundice
causes of indirect hyperbilirubinemia
unconjugated hyper bilirubinemia hemolysis
Hemolysis defect uptake gilbert
defect conjugation Crigler-Najjar syndrome

causes of direct hyperbilirubinemia


jaundice hemolytic jaundice pre
hepatic jaundice hemolysis
hemolysis indirect bilirubin indirect
bilirubin albumin
) (

urobilinogen stercobilin
hemolysis
path way hemolysis indirect
bilirubin uptake conjugation direct
bilirubin conjugated bilirubin intestine
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..............................................................
Liver stercobilinogen Intestine
urobilinogen
colorless urobilinogen

cholestatic Obstructive jaundice


dark urine Itching biliary cirrhosis
Investigation sclera olive green clay stool pain
biliary obstruction

obstructive jaundice
bilirubin bilirubin obstruction data
Gamma gt alkaline phosphatase direct
extra hepatic intra hepatic biliary dilatation
common bile duct biliary obstruction
150
direct bilirubin nephropathy
albumin water soluble bilirubin
dark
kidney tubules endogenous toxin criteria
acute tubular necrosis nephropathy

obstructive hepatocellular jaundice


obstructive jaundice
hepatocellular
jaundice
defect hepatocellular hepatocellular
secretion conjugation uptake
hepatocyte hepatocellular
defect in uptake bilirubin handling
unconjugated bilirubin
102


..............................................................
defect in conjugation unconjugated bilirubin

defect secretion conjugated bilirubin
conjugated unconjugated Obstructive
secretion step liver metabolism very
difficult Liver failure uptake
conjugation secretion
two fraction direct indirect

obstruction
alkaline phosphatase Gamma gt
obstructive
prothrombin time serum
albumin clinically liver cell failure
hepatocellular jaundice
bilirubin bilirubin
mainly direct obstructive hepatocellular

investigation
Gilbert Partial defect in uptake mild defect in
conjugation defect in conjugation
MCQ
uptake conjugation
Indirect bilirubin
autosomal dominant recessive
MCQ
autosomal dominant

103


..............................................................
Mild rise in bilirubin indirect

Investigation hemolysis normal


or reticulocytosis by exclusion gilbert
MCQ bilirubin fasting
bilirubin
normal liver function

Dubin-Johnson defect in secretion secretion of


what conjugated bilirubin Liver
conjugated bilirubin conjugated bilirubin
absorbed in circulation obstructive
hepatocellular jaundice other criteria of biliary
obstruction gilbert isolated defect in uptake
Dubin-Johnson isolated defect in secretion Liver
normal biopsy pigment Liver
(bromsulphthalein (BSP Dubin-
Johnson Liver uptake
bromsuphthalein dye
blood Liver uptake secretion
dye circulation drop
of dye injection dye uptake
secretion Bromsulphthalein
Dubin-Johnson

recurrent jaundice jaundice


jaundice hemolytic gall
stone gall bladder
common bile duct
common bile duct
common bile duct spasm
buscopan
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..............................................................
periampullary carcinoma

recurrent jaundice familial jaundice painful


jaundice painless jaundice

Amoebic liver abscess


written problem solving
cecum
portal vein right lobe of the liver
streaming effect cecum compartment
portal vein amoeba right
lobe of the liver
endemic
right hypo chondrim tenderness
liver Lower border of the
liver right costal margin
tenderness
fist percussion
fist percussion
fist percussion

tender
Intercostal tenderness
intercostal space Liver
fist percussion

Investigations
leukocytosis polymorph
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..............................................................
alkaline phosphatase
right pleura right sided pleural effusion
Anchovy sauce cyst
amoebic liver pleural effusion Liver disease
rigth pleura ascites right pleura
left sided pleural advanced liver cirrhosis
effusion
commonest cause of pleural effusion is
pneumonia
cirrhotic hepatic pneumonia
.T.B
broad spectrum antibiotic infusion

MCQ
leucocyotsis Jaundice + leukocytosis
polymorph
Neutrophilia
fulminant liver failure MCQ
fulminant failure Leucocytosis
tissue necrosis in liver like myocardial infraction
Leucocytosis tissue damage damage

leukocytosis neutrophils amoebic liver
leukocytosis leptospirosis
gall stone ascending cholangitis
jaundice multiple gall stone in bladder
common common bile duct
biliary system stagnation bile duct

106


..............................................................
Infection biliary system stone ascending
cholangitis


GIT

**** !!!!!
"..... ,
" *****

107

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