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Fetor hepaticus - foul smelling breath of a patient in late liver failure Ascites fluid normally contains isotonic Glucose,

Sodium, Potassium, but Increased protein (up to 3 gm/dL) Ascites caused determined by the SAAG (Serum albumin)-(ascites albumin) Values greater than 1.1 indicate portal hypertension as increased capillary hydrostatic pressure forces fluid into the interstitium leaving behind proteins (albumin) If serum albumin is low with an elevated SAAG, this indicates liver damage High serum protein in the setting of SAAG indicates Heart Failure or Budd Chiari Hepatitis A virus is a (+)non-enveloped, ss-RNA virus of the family: Picornaviridae that causes a self-limited serum-sickness-like illness Spread fecal-orally Does not cause Cytotoxic damage; rather immune mediated Patchy areas of inflammation Anti HAV Ab IgM appears at onset of sxs (approximate month incubation) Hepatitis B virus is a Circular dsDNA Virus Long incubation period of 1-4 months Parenteral, Sexual, and perinatal transmission (highest risk of carrier state and HCC genesis) Codes for HBVx gene which may be associated with HCC genesis based on interference with p53; Required for infectivity Also contains a DNA Polymerase with Reverse Transcriptase Activity Chronic Infection has been associated with Polyarteritis Nodosa, and Glomerulonephritis Hepatits C Virus is a (+)ssRNA of Flaviviridae only 25% are capable of clearing the infection and the majority will go on to a stable cirrhotic condition of these a smaller percentage will progress to worsening cirrhosis or HCC Rare acute viral stage presence os HCV Ab DOES NOT confer resistance (as in HBsAb) Transmission via blood innoculum Hepatitis D virus is a defective-circular ssRNA of Deltaviridae requires concurrent HBV infection may occur simultaneously (co-infection); normally cleared or may occur on top of chronic HBV (Superinfection) Causes a much more rapid progression of the hepatitis Parenteral Transmission Hepatitis E virus is non-enveloped ssRNA of Calciviridae Fecal-oral transmission Usually self limited diarrheal illness Associated with a HIGH MORTALITY IN PREGNANT WOMEN Cyst water transmission is unique to protozoa (ie. Cryptosporidium, Giardia, and Entamoeba) Y. enterolitica is associated with mini-epidemics of dysentary, primarily in COLD WEATHER and children Shiga Toxin inhibits 60s Ribosomal subunit HCV can be associated with or cause Cryoglobulinemia and vasculitis Liver Abscesses may be caused by bacteria enterics, such as E. Coli & Klebsiella (increased in DM; more mass-like than other bact abscesses), Strep Viridans, Requires liver dysfunction or huge innoculation (via bacteremia, infection drained via portal system, direct extension, or trauma) Usually in the setting of obstruction causing ascending cholangitis Requires intensive abx therapy and DRAINAGE

Amoebic abscesses (Entamoeba) causes an exquisitely tender liver, is associated with corticosteroid use, and responds rapidly to metronidazole E. histolytica crosses tissue planes readily Do not usually drain unless life threatening, pregnant, left lobe, very large Creates a non-purulent abscess with cellular debris and organisms in the periphery Hepatic Encephalopathy can be treated with Lactulose as it chelates excess ammonium Caroli disease is a form of Congenital Hepatic Fibrosis, characterized by intrahepatic Biliary duct proliferation and ectasia Associated with Polycystic Kidney Disease Causes portal hypertension Associated with a 100x greater risk of Cholangiocarcinoma Diverticulitis is associated with a thickening of the bowel wall For SEVERE Pseudomembranous colitis (ie. Acute Renal failure, Hypotension, and marked leukocytosis), Tx with Oral Vanco for mild infections, oral Metronidazole and Vanco are equivalent Altered Lipid Metabolism in the liver is seen in the setting of Alcoholic Hepatitis as well as NASH the result is an alteration of oxidation leading to: decreased B-oxidation in the liver Increased Uptake and Synthesis of Fatty Acids decreased VLDL PSC has been associated with Positive ANCA Abs (also UC; hence seen together) Fibrolamellar Carcinoma is a subtype/variant of HCC in which nodules are separated by parallel collagenous lamina seen in Hemochromatosis and Tyrosinemia Pts presenting with late onset Diabetes who are thin/malnourished, consider chronic pancreatitis Pancreatic Carcinoma follows a similar pathogenesis to that off Colon Cancer through various mutations culminating in cancer K-Ras mutations early lead to Fos/Jun expression p-16 mutations follow leading to a loss of G1/S checkpoint SMAD-4 and p53 follow with unregulated growth and loss of apoptosis Associated with a desmoplastic reaction Pre-albumin is a better marker for chronic liver disease than is Albumin Administration of Vitamin K helps diagnose Vitamin K deficiency-induced prolonged PT versus liver disease-induced prolonged PT (lack of all clotting factors except V, VIII will NOT be corrected with Vit K administration) Factor V is NOT synthesized in a Vitamin K dependent fashion and therefore can be used as a marker of recovery in liver disease Sialadenitis is caused usually by obstruction and may create an abscess from flora such as S. viridans, and aureus May also be AUTO-IMMUNE (ie. Sjogrens) commonly affects lacrimal and salivary glands Mikulicz Syndrome Esophagitis is characterized by Eosinophils in the the epithelial layer, elongation of Papillae of Lamina Propria and Basal Zone Hyperplasia H. pylori infection is associated with a number of proteases and virulence factors: VacA is a vacuolating protease translated from the CagA gene Stimulation of IL-8 causes a massive influx of PMNs resulting in tissue damage Cholangiocarcinoma aka Klatskin Tumor Bilateral Ovarian tumors secondary to Gastric Carcinoma spread - Kruckenberg Tumor

Stomach Adenocarcinomas may present with Acanthosis Nigricans, a paraneoplastic syndrome Chronic Alcohol INDUCES P450 (located in the smooth ER); as a result, the GGT may be elevated as Increased P450 stimulates GGt synthesis Can be used to Monitor truthfullness regarding Alcohol intake by chronic abusers Yersinia may manifest with systemic symptoms including pericarditis, peritonitis, and pharyngitis Necrotizing granuloma of the peyers patches C. perfringens has been associated with Necrotizing Enterocolitis Mucinase allows V. cholera to colonize sml intestine Shigella evades immune system by cell-to-cell transmission, even though non-motile; accomplished via actin polymerization S. tyhpis infectivity comes from the Vi antigen capsule it possesses UC is associatd with HLA-DRB1 mutations Crohns is associated with HLA-DD7 and DQ4 Celiac - HLA DQ2 and DQ8 Crohns can be identified by Fat Creeping of mesentary around bowel; Hypertrophy and Stricture commonly show up as a String Sign on Barium XR The finding of Diphteroids on lab should raise suspicion of L. monocytogenes mc. occurs in patients who have a diminished cell-mediated immunity ie. Pregnancy (abortion/still born) AIDS , Neonates & Eldery pts (meningitis, cerebritis, abscesses, endocarditis) Gastroenteritis is associated with contaminated food products: Deli meats, soft cheeses Iron is also a growth factor increased occurrence in Hemochromatosis patients and chronic transfusion recipients Virulence factors include Actin-A (adhesion); Listeriolysin-O (evade phagocytosis), and Internalin (endocytosis) Complications include DIC/ARDS/Liver Disease, and Rhabdomyolysis Dental carries - think Actinomycetes Villous blunting (ie. Giardia) cause a malabsorption leading to an osmotic diarrhea Entamoeba (invasive form) causes an ulcerating dysentery with cutaneous perianal and urogenital ulcers (flaskshaped extending into the Submucosa) may also cause R-sided pleural effusions Microsporidia can cause a chronic cachectic wasting state similar to Cryptosporidium the spore is small and resistant with a polar filament Loefflers Penumonitis can occur in the setting of Ascaris or Hookworm (Ancylostoma/Necator) infection Hookworms feed off the blood causing an Iron-deficient Anemia Strongyloides can infect through intact skin; additionally it can: Produce multiple generations within a host Larvae (not eggs) are found in the stool Causes a migrating rash (larva currens) Gram negative meningitis and auto-infection in immunocompromised patients (or using corticosteroids) Transmitted person-person Schistosoma is a blood fluke that causes many mortalities worldwide penetrates healthy skin Causes acute serum-like sickness in non-endemics (Katayama Fever) Snail is an intermediate host (all Trematodes including Liver Flukes) Can migrate to the liver creating periportal fibrosis with hypertension but spares hepatocellular function S. Haematobeum can also infect the bladder and cause fibrosis and even cancer Treat with Praziquantel GISTs may affect the small bowel

Associated with c-KIT mutations and stain CD-117 positive Demonstrates spindle cells Treat with Imatinib Fecal Leukocytes in the setting of infantile dysentery is unique to Shigella (DDx Campylobacter; pts NMYL < 1 y/o) Additional complications include reactive arthritis/Reiters Syndrome, and Rectal Prolapse Reiters Syndrome can also occur in the setting of Campylobacter infection Erythema nodosum also Zn is an important component of fluid replacement therapy Watery diarrhea of the newborn is most likely EPEC or EAEC Paneth Cells are a hallmark of Inflammatory bowel disease (as is Pseudopyloric metaplasia) Basal plasmacytosis is characteristic of UC while Crohns is most often seen with a lymphocytic infiltrate Mumps can produce aseptic meningitis Celiacs disease is associated with an increased risk of MALToma Ascaris life cycle involves aspirating a small worm as the eggs hatch in the lungs Characteristic football-shaped eggs UC can be identified histologically by plasma cell infiltrate and neutrophilic crypt abscesses

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