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85 Cards in this Set
- Front
- Back
What is the #1 hepatic artery variant?
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right hepatic artery off SMA, courses behind pancreas, posterolateral to the common bile duct
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What variant of the left hepatic artery is found in about 20% of the population?
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left hepatic artery off left gastric artery
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What is the most common variant of the common hepatic artery?
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off SMA
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What lobes of the liver does the falciform ligament separate?
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medial and lateral segments of the left lobe
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What does the falciform ligament carry?
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remnant of the umbilical vein
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What carries the obliterated umbilical vein to the undersurface of the liver?
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ligamentum teres
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What separates the right and left lobes of the liver?
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cantle's line drawn from the gallbladder fossa to the IVC
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What is the peritoneum that covers the liver called?
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Glisson's capsule
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The portal triad enters and the gallbladder lies under what two segments of liver?
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IV and V
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What are liver macrophages called?
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Kupffer cells
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What is the orientation of the contents of the hepatoduodenal ligament?
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CBD lateral, hepatic artery medial and portal vein posterior
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What is clamped in the Pringle maneuver?
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portal hepatis
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What are the four borders of the foramen of Winslow?
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anterior - portal triad, posterior - IVC, inferior - duodenum, superior - liver
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What 3 vessels form the portal vein and what is their configuration?
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IMV enters the splenic vein, SMV joins the splenic vein
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How many portal veins in the liver? and what % of the blood supply do they provide?
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2 portal veins in the liver, 2/3 of the blood supply
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What are the hepatic arteries? and veins?
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right, left and middle, same as the veins
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In 80% of the population what is the configuration of the hepatic veins entering the IVC?
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Middle hepatic vein joins left hepatic vein before going into the IVC. In the other 20%, all 3 go directly into the IVC.
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What is unique about the blood supply and drainage of the caudate lobe?
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Caudate lobe – receives separate right and left portal and arterial blood flow; drains directly into IVC via separate hepatic veins
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What membrane of the liver does nutrient uptake occur?
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sinusoidal membrane
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What is the usual energy source for the liver?
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ketones
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What is the only water soluble vitamin stored in the liver?
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B12
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What are the 2 most common problems with hepatic resection?
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bleeding and bile leak
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Which hepatocytes are most sensitive to ischemia?
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central lobular (acinar zone III)
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What % of the liver can be safely resected?
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75%
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Bilirubin is conjugated to what in the liver which improves water solubility?
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glucuronic acid
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What comprises 85% of bile? what is the main phospholipid in bile?
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bile salts, lecithin
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In bile, what is used to make bile acids?
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cholesterol
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What two molecules are bile acids conjugated to in order to make them more water soluble?
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taurine or glycine
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What are the two primary bile acids? the two secondary (dehydroxylated primary acids by bacteria in gut)?
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primary - cholic and chenodeoxycholic
secondary - deoxycholic and lithocholic |
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What level of bilirubin is necessary for jaundice?
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>2.5
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What is the maximum bilirubin possible (unless pt has underlying renal disease, hemolysis or bile duct-hepatic vein fistula)?
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30
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What disease is the abnormal uptake of bilirubin resulting in mildly high unconjugated bilirubin?
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Gilbert's disease
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What disease is the inability to conjugate bilirubin; deficiency of glucuronyl transferase; high unconjugated bilirubin -> life threatening disease.
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Crigler-Najjar disease
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Physiologic jaundice of newborn has high unconjugated bilirubin and is the result of which immature enzyme?
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glcuronyl transferase
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There are two syndromes that have a high conjugated bilirubin. Which one is a deficiency in storage ability and which one is a deficiency in secretion ability?
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Rotor's syndrome is a deficiency in storage ability. Dubin-Johnson syndrome is a deficiency in secretion ability.
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In hep B which Ig dominates in the first 6 months? which one then takes over?
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IgM then IgG
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In Hep B which Anti-HB rises 10-12 weeks after infection? and 12-14? and 14-16?
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10-12 weeks Anti HBc
12-14 weeks Anti-HBe 14-16 weeks Anti-HBs |
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What Ab is elevated in a pt who is vaccinated against Hep B
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Anti-HBs
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If a pt has elevated anti-HBc and elevated anti-HBs antibodies and no HBs antigens, what does that mean?
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pt had infection with recovery and subsequent immunity
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What is the most common viral hepatitis leading to liver TXP?
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Hep C (long incubation period)
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Hepatitis D is a cofactor for which other Hepatitis?
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Hep B
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What does Hepatitis E cause?
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fulminant hepatic failure in pregnancy, most often in 3rd trimester
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What is the most common cause of liver failure?
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cirrhosis
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What is the best indicator of synthetic function in pts with cirrhosis?
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prothrombin time (PT)
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What is the mortality of acute fulminant hepatic failure? The course of what sx determines the outcome?
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80% mortality, encephalopathy
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What is the main medical tx for hepatic encephalopathy and how does it work?
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lactulose is a cathartic that gets rid of bacteria in the gut and acidifies the colon preventing NH3 uptake by converting it to ammonium (titrate to 2-3 stools per day)
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What should you limit the protein intake to in hepatic encephalopathy?
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<70 g/day
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Other than the mainstay, lactulose, name three other medical treatments for hepatic encephalopathy.
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Neomycin, L-dopa, bromocriptine
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When you do a paracentesis for ascites what do you need to replace and what is the dose?
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albumin, 1g for every 100cc removed
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What is increased aldosterone caused by in ascites?
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impaired hepatic metabolism and impaired GFR
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Hepatorenal syndrome has the same appearance as prerenal azotemia what is the tx (2)?
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stop diuretics, give volume
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What is the cause of postpartium liver failure with ascities and how do you dx?
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hepatic vein thrombosis
Dx: SMA arteriogram with venous phase contrast |
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Sx of SBP include fever, abdominal pain, positive cultures and PMNs greater than what level in the fluid?
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250
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SBP is most commonly mono-organism; if it is not then you need to worry about what?
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bowel perforation
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What is the most common organism in SBP?
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E. coli
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What is a risk factor for SBP in children?
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SLE
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What is the tx for SBP?
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3rd -generation cephalosporin; pts usually respond within 48 hrs
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What is 90% effective at treating esophageal varices?
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sclerotherapy
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Name 2 medical treatments for esophageal varices and how they work.
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vasopressin (splanchnic artery constriction)
octreatide (decreased portal pressure by decreased blood flow) |
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In pts with esophageal varices who are on vasopressin and have CAD should get what additional medical tx?
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NTG
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What is the name of the tube for esophageal varices that has a risk of esophageal rupture and is hardly used anymore?
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Sengstaken-Blakemore
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What is the role for propanolol in esophageal varices?
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may help prevent rebleeding; no good role acutely
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Pts who develop strictures after sclerotherapy for esophageal varices are easily managed with what tx? what if they develop refractory variceal bleeding, what tx?
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dilatation, TIPS for refractory bleeding
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What does TIPS stand for?
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transjugular intrahepatic portosystemic shunt
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What is the mortality of bleeding varices with 1st episode? What % will rebleed and what is the mortality with each subsequent bleeding episode?
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33%, 50%, 50%
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50% of portal hypertension in children is caused by what?
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portal vein thrombosis
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What is the normal port vein pressure?
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<12 mmHg
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What procedure would you do for a Child's A cirrhotic that just has bleeding as a symptom?
What if the pt is Child's B or C with indication for shunt (bleeding, progression of coagulopathy, visceral hypoperfusion, refractory ascites)? |
splenorenal shunt (more durable) for A
TIPS for B or C |
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Pts with TIPS are at risk for developing what?
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encephalopathy
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What is the most common cause of massive hematemesis in children?
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portal HTN due to extrahepatic thrombosis of the portal vein
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What is the tx for Budd-Chiari syndrome?
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portacaval shunt (needs to connect to the IVC above the obstruction)
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Isolated gastric varices without elevation of pressure in the rest of the portal system can be caused by what?
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Splenic vein thrombosis
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What is most often the cause of splenic vein thrombosis?
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pancreatitis
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What is the treatment for splenic vein thrombosis?
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splenectomy
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What is the organism in amebic liver abscesses?
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Entamoeba Histalytica
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Risk factors for Entamoeba histalytica include ETOH and travel to Mexico. How do you dx?
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CT characteristics, elevated LFTs, white count, serology (cultures are often sterile since the protozoa exists only in peripheral rim)
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What is the tx for amebic liver abscesses?
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Flagyl; aspiration if refractory of contaminated; surgery only for free rupture
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What is the organism in hydatid liver cysts?
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Echinococcus
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How do you dx echinococcus infections (2 tests)?
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Positive Casoni skin test, positive indirect hemagglutination
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Abdominal CT shows liver lesion with ectocyst (calcified) and endocyt. What is that characteristic of?
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hydatid cyst
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What is the tx for hydatid cyst?
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preop albendazole, surgical removal (may wan to inject cyst with alcohol at time of removal to kill organsims) need to get all of cyst wall
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Why don't you aspirate hydatid cysts?
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can leak out and cause anaphylactic shock
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Pt with hydatid cyst has jaundice, elevated LFTs or cholangitis. What do you need to do preop?
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ERCP to check for communication with the biliary system
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Maculopapular rash, increased eosinophils. Sigmoid colon has fine granulation tissue, petechiae, ulcers and can cause variceal bleeding. What is the dx and what is the tx?
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Schistosomiasis
Tx: praziquantel and control variceal bleeding |
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80% of liver abscess are what type? what is the number one organism?
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pyogenic, E. coli
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