Week 52: Hepatobiliary/Pancreas

Reynolds pentad = Charcots triad (Fever, RUQ pain, and Jaundice), and adds two septic/toxic elements -> Hypotension and AMS!

This answer is tricky, but answers B-D can be ruled out.

Ascending cholangitis is typically treated with urgent biliary decompression and intravenous antibiotics. Reynolds pentad, although classically associated with ascending cholangitis, is rarely present and a high index of suspicion is required for diagnosis. In addition to common duct stones and biliary obstruction, cholangitis should be suspected in patients presenting with sepsis after ERCP.

Although biliary colic in the absence of acute cholecystitis can typically be managed as an outpatient with symptoms control and surgical referral, in special populations such as children and prolonged symptoms in pregnancy may require admission. Acute cholecystitis requires prompt (in ED) surgical consultation and admission.

The presence of this antibody either represents natural immunity from successfully resolved Hepatitis B infection or the desired response to vaccination

While an elevated serum ammonia level is highly indicative of hepatic encephalopathy, a normal level does not rule out the diagnosis. A head CT should always be considered in a patient with altered mental status. An elevated ethanol level may account for this patient’s symptoms, but with his confusion and history of liver disease, other sources must be explored. Blood glucose levels should be checked frequently since this patient with liver disease has likely impaired glucogenesis and reduced glycogen stores.

In severe acute liver failure, transplant is often the only means to improve survival. Thus, transfer to a transplant facility is vital. Oral charcoal is of no real benefit after approximately 3 to 4 hours after ingestion. N-acetylcysteine may still be of some benefit, even up to 48 hours after ingestion.

Despite the potential for pulmonary edema in acute hepatic failure, intravenous fluids should be given as part of the initial resuscitation. Propofol is a recommended agent for the patient requiring sedation. Flumazenil has not been shown to be efficacious in the patient with liver failure and altered mental status. Fresh frozen plasma is necessary to correct the coagulopathy in the liver failure patient with bleeding.

With an incidence of 17% to 28%, biliary complications—bile leaks and instructions to bile flow from strictures, stones, ampullary dysfunction—are the most common and anastomotic complications of orthotopic liver transplant. Hepatic artery thrombosis less commonly complicates orthotopic liver transplant; however, it is more common than portal vein thrombosis or hepatic vein thrombosis.

Hyperparathyroidism can lead to hypercalcemia. This can lead to the inappropriate release of proteolytic enzymes that can lead to acute pancreatitis.

Chronic pancreatitis damages the Islet of Langerhans, impairing the secretion of insulin and glucagon, predisposing the patient to episodes of acute hypoglycemia.