Obesity, Metabolic syndrome

• Metabolic syndrome: Central obesity, HTN, insulin resistance, and

hyperlipidemia.
• BMI over 30 (obese). Plus 2 of either:
- BP over 130/85.
- TG over 150 mg/dL.
- HDL below 40 mg/dL.
- Fasting glucose of over 100 mg/dL (5.5 mmol/L). Or known DM2.
• May lead to: HTN, Arthritis, CAD, Gout, GERD, Sleep apnea, cancers,
PCOS, Diabetes, stroke, Non-alcoholic fatty liver disease.
Pancreas, Liver, Gallbladder
 Topics
51. Cholelithiasis and its complication
52. Acute and chronic pancreatitis
53. Acute hepatitis
54. Chronic hepatitis
55. Liver cirrhosis
56. Portal hypertension – classification, complication, therapy, and prognosis
57. Acute and chronic liver failure
58. Tumors of liver, bile duct, gallbladder, and pancreas
51. Cholelithiasis and its complication
• Cholelithiasis: “gallstone”.
• Can be cholesterol (most common) or bilirubin stones.
- Cholesterol: radiolucent, 40s women, obese, pregnant, contraceptives, fibrates,
Crohn disease, cirrhosis.
- Bilirubin: radiopaque, hemolytic anemia, cirrhosis, biliary tract infection.
• Diagnose with ultrasound.
• Usually gallstones are asymptomatic.
Cont.
• Complications:
• Acute pancreatitis.
• Biliary colic: gallbladder is contracting against a lodged stone in cystic duct. Nausea/vomiting.
• Acute cholecystitis: stone  dilatation  pressure ischemia  bacterial overgrowth (E.coli).
- Right upper quadrant pain, fever, WBC, nausea, vomiting.
- ALP is high!
• Chronic cholecystitis: due to longstanding gallstone.
- Vague pain after eating.
- Leads to porcelain gallbladder  cancer.
• Ascending cholangitis: blockage  stasis  bacterial overgrowth (E. coli).
- Triad: jaundice, fever, right upper quadrant pain (altered mental status + shock).
• Fistula: between gallbladder and GIT  stone goes into GIT  gallstone ileus at ileocecal valve.
• Gallstone cancer: symptoms of cholecystitis in an elderly woman.
52. Acute and chronic pancreatitis
• Acute pancreatitis:
• Most common causes: alcohol or gallstones.
• Due to autodigestion by enzymes.
• Acute epigastric pain that spreads to the back.
• High serum amylase/lipase.
• CT scan.
• Ranson’s criteria: keep an eye on glucose, age (over 55), LDH, AST, WBC.
• Check LFT (ALK-P) and do ultrasound to identify gallstone pancreatitis.
• Complications: pseudocyst, pancreatic necrosis, hemorrhage, infection, ARDS, renal failure,
hypocalcemia, ascites.
Cont.
• Chronic pancreatitis: atrophy and calcification of pancreas due to repeated acute
pancreatitis because of alcohol abuse.

• Severe pain in epigastrium and radiates to the back like acute, accompanied by nausea and
vomiting.

• Order a CT and order Ultrasound and see calcified pancreas (calcified pancreas is 100% proof
of disease).

• Do ERCP because serum amylase and lipase are not elevated.

• Complications: DIABETES!, steatorrhea, pseudocyst formation, fat-soluble vitamin deficiency.

53. Acute hepatitis
• Fever, jaundice, hepatosplenomegaly, arthralgia, dark urine.
• High ALT/AST.
• Less than 6 months.
• Detect IgM antibody against HepA virus.
54. Chronic hepatitis
• Symptoms last longer than 6 months
• Mainly hepatitis viruses B and C.
• May lead to cirrhosis, fulminant hepatic failure, or hepatocellular
carcinoma.
• HBsAg = infection.
• Anti-HBc antibody = IgM means acute. IgG means chronic.
• For Hepatitis C, check anti-HCV antibody.
• For Hepatitis D, check anti-HDV antibody.
55. Liver cirrhosis
• Diffuse bridging fibrosis (by stellate cells) + regenerative nodules.
• Splenomegaly, hard shrunken liver, jaundice, hypoglycemia, hyponatremia
(because of the massive water retention), elevated ALT/AST.
• Causes hepatorenal syndrome, ascites and pitting edema (low albumin),
portal HTN, hypercoagulation, encephalopathy (flapping tremor).
• Hyperestrinism: spider angiomas, gynecomastia, palmar erythema,
testicular atrophy.
• Spontaneous bacterial peritonitis: happens in patients with cirrhosis and
ascites. Caused by E. coli.
• Increased risk of hepatocellular carcinoma.
56. Portal hypertension – classification,
complication, therapy, and prognosis
• Classification:
- Prehepatic: portal vein thrombosis, extrinsic compression.
- Pre-sinusoidal  schistosomiasis, idiopathic, metastasis.
- Sinusoidal  cirrhosis, severe hepatitis.
- Posthepatic: Budd-Chiari syndrome, RHF.

• Complication: ascites (DO PARACENTESIS), hypersplenism (anemia), bleeding.

• Therapy: TIPS + octreotide + ligation.

• Prognosis is BAD if hepatic encephalopathy is bad along with old age, low albumin, high INR.
57. Acute and chronic liver failure
• Acute liver failure: Coagulopathy (INR above 1.5) and encephalopathy in a patient with a previously
healthy liver.
- PT is also high.
- Up to 26 weeks.
- Caused by: Amanita mushrooms, viral hepatitis, paracetamol overdose, Budd-Chiari syndrome (liver infarction),
malignancy.
- Signs: jaundice, encephalopathy, tremor flap/asterixis, ascites.
- If caused by paracetamol, check pH because it can cause acidosis.

• Chronic liver failure = cirrhosis.

• Order CBC, Creatinine, ALT/AST, glucose, paracetamol level, blood culture, abdominal ultrasound, x-ray.
• Beware of sepsis, hypoglycemia, GI bleeding (varices), encephalopathy (brain edema  ICP).
• Give warfarin, mannitol (brain edema), Abx (infection), glucose if hypoglycemic, lactulose.
• LIVER TRANSPLANT!
58. Tumors of liver, bile duct, gallbladder,
and pancreas
• Tumors of liver: hepatocellular carcinoma.
- Risk factors include chronic hepatitis, cirrhosis, NAFLD, hemochromatosis, A1AT deficiency.
- Increased risk for Budd-Chiari syndrome: hepatic vein obstruction  liver infarction  painful
hepatomegaly/ascites/portal HTN.
- Serum tumor marker is a-fetoprotein.
- Tumors are often detected late because symptoms are masked by cirrhosis (jaundice, portal HTN, ascites, etc.).
- Order liver biopsy, CT, ultrasound.

• Tumor of the bile duct: cholangiocarcinoma.

- Tumor of intrahepatic or extrahepatic bile ducts.
- If it’s in the proximal 1/3 of the common bile duct, we call it Klatskin’s tumor. This tumor involves both left and right
hepatic ducts and so it has very poor prognosis because they are unresectable.
- Main risk factor is Primary Sclerosing Cholangitis: “Onion skin” bile duct fibrosis. Common in Ulcerative Colitis.
- Patient will have obstructive jaundice, dark urine, light colored stool, pruritus.
- Order cholangiography (ERCP).
Cont.
• Pancreatic carcinoma: tumor marker is CA 19-9. Also CEA.
- Abdominal pain radiating to the back.
- Weight loss.
- Migratory thrombophlebitis in the extremities.
- obstructive jaundice with palpable non-tender gallbladder (mass)
- Order CT + ERCP.

• Gallbladder carcinoma:
- Gallstones are a major risk factor, especially when it causes chronic cholecystitis, and then
porcelain gallbladder.
- Presents as cholecystitis in an elderly woman.
- Jaundice, RUQ pain/mass, weight loss.