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Autoimmune Hepatitis

Key Points 1 Criteria for the diagnosis of autoimmune hepatitis have been codified with development of two diagnostic scoring systems that can support clinical judgment in the diagnosis of difficult cases. 2 Presentations range from acute severe (fulminant) to asymptomatic and mild. 3 Genetic factors within ( DRB1∗0301 , DRB1∗0401 , DRB1∗1301 , DQB1∗0201 , DRB1∗07 ) and outside (diverse polymorphisms) the major histocompatibility complex (MHC)…

Hepatitis Caused by Other Viruses

Key Points 1 Systemic viral infections can cause liver injury that ranges from mild asymptomatic and transient elevation of serum aminotransferase levels to acute icteric hepatitis or rarely severe hepatitis with acute liver failure (ALF). 2 The clinical presentation may be indistinguishable from liver injury caused by the principal hepatotropic viruses. 3 Mild liver enzyme elevations are a common feature of many systemic viral infections and…

Hepatitis C

Key Points 1 Infection with the hepatitis C virus (HCV) is a major cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC), as well as the leading indication for liver transplantation in Western countries. 2 HCV infection is also implicated in a number of metabolic, immunologic, cardiovascular, and neuropsychiatric extrahepatic manifestations, including mixed cryoglobulinemia, cutaneous vasculitis, membranoproliferative glomerulonephritis, porphyria cutanea tarda, non-Hodgkin lymphoma, diabetes mellitus, insulin…

Hepatitis B and Hepatitis D

Key Points 1 Hepatitis B virus (HBV) infection is a major cause of acute liver failure, cirrhosis, and hepatocellular carcinoma (HCC). 2 HBV infection can be prevented by hepatitis B vaccination. 3 Acute HBV infection is most likely to resolve spontaneously in immunocompetent adults, especially if symptomatic. Progression to chronic infection is typical in children, the elderly, and immunocompromised persons, including hemodialysis patients. 4 HCC related…

Hepatitis A and Hepatitis E

Key Points 1 Infection by the nonenveloped, enterically transmitted viruses, hepatitis A virus (HAV) and hepatitis E virus (HEV), generally causes self-limited infection, but severe hepatitis may develop in some cases; chronic hepatitis E has been recognized in immunosuppressed patients and can result in hepatic fibrosis and cirrhosis. 2 HEV genotypes 1 and 2, involved in acute HEV infection, are transmitted by the fecal-oral route, whereas…

Acute Liver Failure

Key Points 1 Acute liver failure (ALF) is an uncommon but dramatic clinical syndrome that is associated with a high risk of mortality. 2 The defining features of ALF reflect mental status changes (i.e., hepatic encephalopathy [HE]) and coagulopathy in patients without preexisting liver disease. 3 Acetaminophen hepatotoxicity is the leading cause of ALF in the United States; nearly 50% of acetaminophen ALF cases reflect unintentional…

Assessment of Liver Function and Diagnostic Studies

Key Points 1 Reflecting the liver’s diverse functions, the colloquial term liver function tests (LFTs) includes true tests of hepatic synthetic function (e.g., serum albumin), tests of excretory function (e.g., serum bilirubin), and tests that reflect hepatic necroinflammatory activity (e.g., serum aminotransferases) or cholestasis (e.g., alkaline phosphatase [ALP]). 2 Abnormal liver biochemical test results are often the first clues to liver disease. The widespread inclusion of…

Clinical Vignettes

Chapter 1—Swallowing Disorders and Dysphagia A 28-year-old internal medicine resident presented to the emergency department with food impaction after eating a chicken sandwich at a noon conference. He was unable to swallow his own saliva and presented for medical attention after 2 hours. He reports no gastrointestinal symptoms until 5 years prior to this event, when he developed food impaction after eating a large piece of…

Colorectal Surgery: Polyposis Syndromes and Inflammatory Bowel Disease

1. Identify four different classes of intestinal polyps. Neoplastic (adenomatous, tubular, villous, tubulovillous, serrated) Hamartomatous Inflammatory and lymphoid Hyperplastic 2. What is a hamartoma? A hamartoma is an exuberant growth of normal tissue in an abnormal amount or location. An isolated hamartomatous polyp has no malignant potential. 3. Which intestinal polyposis syndromes are associated with hamartomatous polyps? Peutz-Jeghers syndrome (PJS) Juvenile polyposis (familial or generalized) Cronkhite-Canada…

Esophageal Surgery

Achalasia 1. Define achalasia. What are the classic findings of esophageal achalasia? Achalasia is a primary motility disorder of the esophagus characterized by a loss of enteric neurons leading to absence of peristaltic waveform in the body and impaired relaxation of the lower esophageal sphincter (LES) in response to swallowing. The condition is relatively rare, occurring at an incidence of 0.5 to 1 per 100,000 of…

Noninvasive GI Imaging: Ultrasound, Computed Tomography, and Magnetic Resonance Imaging

General 1. How has multidetector computed tomography (MDCT) changed the evaluation of the liver, pancreas, and biliary system? MDCT allows for the rapid acquisition of images using very thin collimation (0.6 mm) and reconstruction intervals (0.5 mm). Using these true isotropic volumetric data sets, exquisite multiplanar reformations (MPR) in the coronal, sagittal, or any other imaging plane can be created ( Figure 69-1 ). Imaging can…

Interventional Radiology I: Cross-Sectional Imaging Procedures

Image-Guided Percutaneous Biopsies and Fluid Aspiration and Drainage 1. What are the indications for image-guided percutaneous needle biopsy (PNB)? Establish a benign or malignant diagnosis of a lesion. Stage patients with known or suspected malignancy when metastasis is suspected. Obtain material for microbiological analysis in patients with known or suspected infection. Determine the nature and extent of diffuse parenchymal diseases (e.g., cirrhosis, organ transplant rejection, glomerulonephritis).…