Professional Documents
Culture Documents
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..............................................................
columnar metaplasia
columnar
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
..............................................................
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
weight loss
..............................................................
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
..............................................................
:::
ballon dilation
common used
..............................................................
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
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
11
..............................................................
proton
pump inhibitor
proton pump inhibitor
laparoscope
GERD myocardial ischaemia
clinical
related
ischaemia GERD
Ischeamic heart GERD
psychogenic pure
motility disorder
12
..............................................................
....
..............................................................
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
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
..............................................................
serum prothrombin time serum albumin
billrubin
half life albumin
serum albumin negatively half life
sever chronic liver disease
chronicity + severity
..............................................................
decompensated
hepato cellular
damage liver
liver
virus B virus C drugs cupper
17
..............................................................
sever mild elevation mild form hepatitis
form
alkaline phosphatase
acute viral hepatitis
significant biliary
mechanical obstruction
18
..............................................................
cholestasis direct
billirubin bile salts retain in blood
alkaline phosphatase direct billirubin
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
20
..............................................................
obstruction
liver biliary obstruction hyper
lipidemia hyper cholesterolemial primary biliary
cirrhosis
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
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
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
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
..............................................................
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
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
..............................................................
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
29
..............................................................
protection
Mainly endemic areas
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
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
32
..............................................................
infection vaccine
vaccine
surface antigen genetically engineered
surface antibody
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
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
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
( )
40
..............................................................
management of a case of fever and just
palpable spleen
clinical picture
investigation treatment
management diagnosis treatment
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
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
..............................................................
C glomerulonephritis
cryoglobulin
) (
C
C positive cryoglobulin
glomerulonephritis
!!!
+
C urine analysis
proteinuria investigation
cryoglobulin in blood C
cryoglobulin cryoglobulin
glomerulonephritis
steroid
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
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
..............................................................
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
47
..............................................................
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
51
..............................................................
chronicity
investigations
PCR Liver enzymes
PCR
negative
variable
flu like , arthralgia , fever
paracetamol responding
Ribavirin combination
hepatitis C
lamivudine antiviral
lamivudine oral
52
..............................................................
bilharziasis liver cirrhosis
bilhazia
hepatitis
pure bilharziasis fibrosis cirrhosis
..............................................................
hepatoma Danazol
idiosyncrasy Halothane
hepatitis
idiosyncrasy
medication metabolite metabolite
54
..............................................................
spontaneous bacterial peritonitis SBP
..............................................................
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
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
..............................................................
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
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
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
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
..............................................................
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
65
..............................................................
chest auscultation
crepitation
TVF Percussion chest
abdomen
liver, spleen and ascites
systems Part general
examination
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
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
69
..............................................................
Liver parenchyma
inflammatory process
steato hepatitis NASH
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 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
..............................................................
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
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
..............................................................
azathioprine cyclosporine Liver
transplantation
..............................................................
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
..............................................................
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
..............................................................
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
81
..............................................................
false
neurotransmitter
..............................................................
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
:::
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
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
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
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
..............................................................
systems
ascites
criteria criteria
criteria system
tense lower limb edema
ascites Lower limb edema
edema
ascites tense
file
Lower limb edema ascites moderate
ascites
..............................................................
diuretics diuretics
Na excretion water
Low salt syndrome diuretics
fluid restriction
diuretics
..............................................................
160 lasix 400 full dose spironolactone
refractory
diuretic resistance
diuretics
Ultrafiltration Le veen shunt albumin infusion
TIPSS & reinfusion
transplantation
..............................................................
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
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
injection sclerotherapy
sclerosing material bucrylate
histoacryl
Sanfgestaken or Minnesota tube momentary
transient
best treatment rupture varices injection
sclerotherapy
96
..............................................................
k
Sangstaken or Minnesota tube
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
aggravating factors
diuretics Infection
sonar normal
focal lesion in liver alpha feto protein CT
scan MRI hepatoma
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
Embolization
artery
gel foam hepatoma
liver Localized surgical resection
partial Localized Liver compensated
hepatoectomy
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
..............................................................
Liver stercobilinogen Intestine
urobilinogen
colorless urobilinogen
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
..............................................................
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
..............................................................
periampullary carcinoma
tender
Intercostal tenderness
intercostal space Liver
fist percussion
Investigations
leukocytosis polymorph
105
..............................................................
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