Chronic liver disease

Question 1

what are causes of ascites with a SAAG > 11 g/L?

Answer 1

portal hypertension

• cardiac
• liver
• respiratory

Question 2

what are causes of ascites with a SAAG < 11 g/L?

Answer 2

bowel obstruction 
pancreatitis 
biliary ascites 
nephrotic syndrome 
peritoneal malignancy 
post operative lymphatic leak 
serositis (i.e. SLE)

Question 3

what is ascites managed?

Answer 3

dietary sodium restriction
fluid restriction if sodium high
aldosterone antagonist e.g. spironolactone
prophylactic antibiotics i.e. oral ciprofloxacin
paracentesis

Question 4

if you were carrying out a large volume paracentesis (> 5 l) why would you give albumin cover?

Answer 4

to prevent circulatory collapse

Question 5

what are features of chronic liver failure?

Answer 5

compensated: deranged LFT’s
- petechiae
- gynaecomastia
- abnormal hair loss
- distended vessels e.g. caput medusa

decompensated:

• ascites (SAAG < 11g/L)
• encephalopathy
• jaundice (conjugated)
• variceal haemorrhage

Question 6

when performing a paracentesis, when would you give prophylactic antibiotics?

Answer 6

if SAAG < 15g/L to reduce risk of spontaneous bacterial peritonitis
oral ciprofloxacin

Question 7

how would you manage an upper GI variceal haemorrhage?

Answer 7

ABC, FFP, vitamin K
terlipressin
endoscopic variceal band ligation

2nd line: sengstaken-blakemore tube

3rd line: transjugular intrahepatic porto systemic shunt (TIPSS)

Question 8

what are features of hepatic encephalopathy?

Answer 8

cognitive impairment 
asterixis (flapping tremor)
constructional apraxia: cannot draw a 5 pointed star 
raised ammonia level 
triphasic slow wave on EEG

Question 9

what is first line management of hepatic encephalopathy?

Answer 9

lactulose + rifaxim

• lactulose promotes excretion of ammonia and increases metabolism of ammonia by gut bacteria
• rifaximin modlates gut bacteria to reduce ammonia