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Gastroenterology > 20.7.2013 > Flashcards

20.7.2013 Flashcards

0
Q

Precipitating factors for hepatic encephalopathy

A 
Hypokalemia
Alkalosis(diarrhoea,diuretics)
Constipation
High protein diet
SBP
Opioids 
Sedative hypnotics
Hematemesis
Shunt,TIPS
ALF
progressive hepatocellular dysfunction
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1
Q

Substances elevated in hepatic encephalopathy

A 
Ammonia
False Neurotransmitters
Mercaptans
Myoinositol
Neurosteroids
  allopregnanenolone
  Tetrahydrodeoxycorticosterone
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2
Q

First sign and symptom of hepatic encephalopathy

A

Sign-constructional apraxia

Symptom-altered sleep pattern

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3
Q

Dietary management in hepatic encephalopathy

A

Replacement of animal protein by vegetable protein

Diet rich in branched chain amino acids

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4
Q

Goal of lactulose therapy

A

2-3 loose stools per day

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5
Q

Side effects of neomycin

A

Renal toxicity

Ototoxicity

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6
Q

Side effects of metronidazole

A

Peripheral neuropathy

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7
Q

Trace mineral supplement helpful in hepatic encephalopathy

A

Zinc

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8
Q

Effectiveness of beta-blocker therapy

A

25% reduction in resting pulse rate

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9
Q

Calculation of Hct from Hb

A

Hb*3

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10
Q

Neck flexors

A

Strap muscles

Sternocleidomastoid

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11
Q

Neck extensors

A

Longus colli

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12
Q

Asterexis is seen in which grades of hepatic encephalopathy

A

Grade 2 and 3

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13
Q

Grade 1 hepatic encephalopathy

A

Sleep reversal
Mild confusion
Irritability
Tremor

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14
Q

Grade 2 hepatic encephalopathy

A

Disorientation
Lethargy
Inappropriate behaviour
Asterixis

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15
Q

Grade 3 hepatic encephalopathy

A

Severe confusion
Somnolence
Aggressive behaviour
Asterixis

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16
Q

EEG in hepatic encephalopathy

A

Slow,high amplitude,triphasic waves

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17
Q

Role of blood ammonia level in hepatic encephalopathy

A

Neither sensitive and nor specific

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18
Q

Initial dose of lactulose

A

15-45ml bd or qid

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19
Q

Contraindications to oral lactulose

A

Ileus

Bowel obstruction

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20
Q

Dose of rifaximin

A

400mg PO tid

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21
Q

Structures affected in hepatic encephalopathy

A

Cerebellum

Basal ganglia

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22
Q

Causes of elevated blood ammonia level

A 
GI bleeding
Urea cycle disorders
Proline metabolism disorders
Diuretics
Alcohol
Narcotics
Valproate
CKD
Cigarette 
Muscle exertion and ischemia
High body temperature 
Tourniquet use while blood sampling
High protein diet
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23
Q

Role of arterial ammonia level

A

Elevated levels(more than 150mg/dl) are predictive for cerebral edema and brain herniation in acute liver failure

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24
Q

Name of grading system of hepatic encephalopathy

A

West haven

25
Q

Highly specific test for diagnosis of hepatic encephalopathy

A

PSET

portosystemic encephalopathy syndrome test

26
Q

Neuromuscular findings in Grade 1 hepatic encephalopathy

A

Tremor

Incoordination

27
Q

Neuromuscular findings in grade 2 hepatic encephalopathy

A

Asterixis
Ataxic gait
Slow and slurred speech

28
Q

Neuromuscular findings in grade 3 hepatic encephalopathy

A 
Muscular rigidity 
Clonus
Nystagmus
Babinski
Hyporeflexia
29
Q

Latest tests in hepatic encephalopathy

A

Critical flicker frequency test
MRS
TAPIR(MR T1 mapping with partial inversion recovery)

30
Q

Indication for lactulose enema in hepatic encephalopathy

A

Pts at risk of aspiration

31
Q

First line agents in Rx of hepatic encephalopathy

A

Non absorbable disaccharides

32
Q

Rx of mild hepatic encephalopathy in pts with cirrhosis and adult onset diabetes

A

Acarbose

Increases saccharolytic to proteolytic bacteria ratio

33
Q

Drugs that enhance ammonia excretion in urine

A

Sodium benzoate
Sodium phenylbutyrate
Sodium phenylacetate

34
Q

Why zinc is beneficial in hepatic encephalopathy?

A

Zinc increases the activity of Ornithine transcarbomylase

35
Q

Artificial liver

A

MARS

molecular adsorbant recirculating system

36
Q

Drug useful in grade 3 and 4 hepatic encephalopathy

A

Flumazenil

37
Q

Amino acids useful in Rx of hepatic encephalopathy

A

LOLA
L-Ornithine L-Aspartate
Efficacy comparable to lactulose

38
Q

What is MARS?

A

Extra corporeal albumin dialysis

39
Q

Subtle signs of hepatic encephalopathy are seen in _____ % of pts with cirrhosis

A

70

40
Q

Diff btw hepatic encephalopathy due to ALF and cirrhosis

A

Brain Edema plays a prominent role in HE due to ALF

41
Q

Categories of hepatic encephalopathy

A

Type A- ALF
Type B- portosystemic Bypass without hepatocellular disease
Type C- cirrhosis

42
Q

Histologic change in hepatic encephalopathy in cirrhosis

A

Alzheimer’s type 2 astrocytosis(absent in ALF)

43
Q

Neurotoxic substances in hepatic encephalopathy

A 
Ammonia
Manganese
Short chain fatty acids
False Neurotransmitters 
Mercaptans
GABA
44
Q

False Neurotransmitters

A

Octapamine
Tyramine
Betaphenylethanolamine

45
Q

Important site of ammonia detoxification in cirrhosis

A

Skeletal muscle
Contain Glutamine synthetase
Skeletal muscle wasting in chronic cirrhosis increases hyperammonemia

46
Q

Neurosteroid hypothesis in hepatic encephalopathy

A

Ammonia and manganese increase the expression of peripheral type Benzodiazepine receptor in astrocytes
Stimulation of PTBR results in increased production of neurosteroids
Neurosteroids stimulate GABA receptor

47
Q

Grade zero hepatic encephalopathy

A

Covert hepatic encephalopathy

48
Q

Causes for Asterixis

A

HE
uremia
Pulmonary insufficiency
Barbiturate toxicity

49
Q

Cause of fetor hepaticus

A

Mercaptans

50
Q

MRI finding in hepatic encephalopathy

A

Hyperintensity of Globus pallidus due to manganese deposition

51
Q

Rx of HE pt with severe agitation

A

Haloperidol

52
Q

Why vegetable proteins are preferred in HE?

A

Contain dietary fibre

Decreased aromatic amino acids

53
Q

Rifaximine?

A

Non absorbable derivative of rifampin

54
Q

Use of rifaximine

A

Travellers diarrhoea

HE

55
Q

Mechanism of action of LOLA

A

Stimulates urea cycle

Both aminoacids are substrates for glutamate transaminase,increased synthesis of glutamate

56
Q

MOA of sodium benzoate

A

Combines with glycine to form hippurate which is excreted renally

57
Q

MOA of sodium phenylbutyrate

A

Converted to phenylacetate which combines with Glutamine to form phenylacetylglutamine

58
Q

Drug that can be given to improve sleep in hepatic encephalopathy pts

A

Hydroxyzine 25mg at bedtime

59
Q

Urine osmolality in hyponatremia

A

Less than 100 mosm/L

Specific gravity less than 1.003

Gastroenterology (11 decks)

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