1. NO Rx.
  2. Rx. Ursodeoxycholic Acid
  3. Rx. I. anticoagulation & surgical Porta-caval shunting, or porta-atrial shunting; II. Transplant
  4. - This map shows the steps needed to reach the underlaying cause of liver disease. - After establishing that a patient has signs & Symptoms(=S.&S.) of liver disease, you must look for clues in the history(=Hx.), History & Physical exam(=H&P), or associated(=a/w) current diseases in order to come to a preliminary diagnosis. - After Reaching the preliminary diagnosis, one must next confirm this diagnosis with the most specific Investigation(=Inv.). - Most common cause of liver disease is HCV, thus if you are not sure what to do next always do something related to HCV. - Ascites, liver or spleen size does not help in reaching an exact cause of the liver disease; - A small liver or a samll kidney are indications of end-stage organ failure. -1st step in any patient with suspected liver disease is to order LFT &, coagulation tests &, alkaline phosphatase w. Gamma-glutamyl transpeptidase(GGPT) levels. - Wernicke's encephalopathy, alcohol withdrawal, & delirium tremens do not always have obvious, or chronic liver disease. - Viral Hepatitis E is most dangerous in pregnancY. - The main determinant of HBV infectivity is the presence of HBe-Ag. - Most common cause(=MCC.) of liver CA. is HCV, the 2md MCC. is HBV. - MCC. of CA death in the world is liver CA. - HDV is only possible if pt. is IV drug abuser& pt. already infection of HBV. - Any drug side effect (=SE.) it is best to think of which system, or organ is involved and test for the function of that organ on follow up. it is not practical to remember the exact SE. as often one drug can cause to opposite S.&S. or varying degrees of a related finding for example Ribavirin can cause anemia, leukopenia, or even pancytopenia, all SE. will be found on a CBC w/ Diff., thus remembering that Ribavirin is a/s Hematological SE. is easier to remember, and will make you clinically order the correct test.
  5. Sever Unresponsive itching &
    1. Hx. WOMEN S.&S. osteoprosis(HIGH alkaline phosphatase), arthralgia, dark sun-exposed skin(=melanosis),xanthoma; a/w autoimmune diseases e.g: Sjögren syndrome, scleroderma, or CREST synd.
      1. Dx.primary BILIARY CIRROSIS(pBc)
        1. Inv.:antimitochondrial antibodies (AMA) w/ M2,& hypercholesterolemia
    2. Hx. MEN, recurrent stone; a/w IBD(esp.UC), cholangiocarcinoma
      1. Dx. Primary SCLEROSNG CHOLANGITIS(pSc)
        1. Inv.: Perinuclear antineutrophilic cytoplasmic antibodies (pANCA),& Endoscopic retrograde cholangiography (ERC) shows: disseminated intra-hepatic & extra-hepatic bile duct strictures
  6. Tender hepatomegaly &rapidly developing- MASSIVE ascites
    1. Dx.BUDD-CHIARI SYND
      1. Inv. transcutaneous liver Doppler ultrasound
  7. Hx. catheterization liver irradiation ,chemotherapy, myeloproliferative syndrome,or bone transplant; In peads. hx. umbilical vein catheterization
    1. Dx. portal vein thrombosis
      1. Inv. Doppler ultrasound, CT angiography (CTA), or MR angiography (MRA)
  8. S.&S. vary from mild confusion, to severe CNS depression
    1. Hx. Psychosis & Chorea
      1. Dx. Wilson's disease (Hepatolenticular degeneration)
        1. Inv.: ceruloplasmin level & ophthalmology referral to look for Kayser-Fleischer ring
          1. Rx. Penicillamine
    2. Hx. recent GI bleed=INCR. Pr. & BUN=INCR. ammonia, asterixis, hyperreflexia
      1. Dx. Hepatic Encephalopathy(serum ammonia is useful, but not specific)
        1. Rx.low Pr. diet & I. Lactulose, II. Neomycin
    3. 1-2days after alcohol cessation, tremor, sweeting
      1. Dx. Alcohol Withdrawal
        1. Rx. Diazepam(IM), as needed
      2. if sever withdrawal may develop SEIZURE ,combative,HALLUCINATION (VISUAL&auditory), INCR. BP, Pulse,& RR
        1. Dx. Delirium Termens
    4. deficiency of thiamine (vitamin B1)=Hx. Impaired nutrition (alcohol or drug abuse, CA, TPN), Ataxic gait,oculomotor dysfunction
      1. Dx. Wernicke Encephalopathy
        1. Rx. thiamine (IM) w/ proper nutrition
      2. if severe, anterograde & retrograde amnesia, confabulation,
        1. Dx. Korsakoff's syndrome
  9. common non-specific liver disease S.&S.
    1. jaundice
    2. hepato-renal syndrome
    3. gynecomastia
    4. spider angiomata
    5. palmar erythema
    6. ascites
      1. Rx.I Salt restriction, II. Sprionolacton (to antagonise the hyper-aldosterone state of liver disease), III. Slow tapping of up to 2L ascites daily balanced with infusion of 10g albumin per liter tapped, IV. Peritoneo-jugular shunt
    7. itching, scratch mark(excoriation)
      1. Rx. moisten skin, anti-histamine, topical steroids
    8. increased TP
      1. not bleeding
        1. no Rx.
      2. bleeding
        1. Rx. Fresh Frozen Plasma
    9. Varices
      1. propanolol
      2. banding if bleeding
  10. Multi-systemic S.&S.: psudo-gout, heart disease, dark skin, infertility, DM
    1. Dx. Hemochromatosis
      1. Inv. Fe & Ferritin levels
        1. Rx. Phlebotomy
  11. aLt Higher then aSt, Hx. Drug IV abuse
    1. Dx.virL
      1. order: viral hepatitis serology
        1. All ACUTE viral Hepatitis present the same (pain, dark urine, fatigue, and anorexia) with no chronic liver disease S.&S.
          1. Rx. of All viral hepatitis is hydration if needed & NO medication
        2. MCC. CHRONIC viral Hepatitis is HCV, followd by HBV both have chronic liver Disease, Rx. ONLY IF
          1. HCV- Bx. showing a viable liver w/ active disease & positive HCV Ab. & PCR positive HCV viral load
          2. Rx. is 2 drugs: Interferon-Alfa-2b & Ribavirin
          3. HBV- HBe Ag positive for more then 6 months
          4. Rx.is only ONE drug: Interferon Alfa-2b, OR Lamivudine. OR Adefovir
  12. aSt is Higher then alt, Hx. patient on any medication, or alcoholic
    1. Dx. drugS induced liver disease
      1. Rx. stop the drug
  13. Hx. respiratory disease
    1. Dx.alfa 1-antitrypsin deficiency
      1. Inv. alfa 1-antitrypsin level
        1. Rx. alpha-1 antitrypsin(IV)