Definitions, Tables, Facts - Gastro Flashcards
1
Q
Causes of acute liver failure
A
Paracetamol Mushroom poisoning Drug induced - esctasty, metamphet, valproate, isnoniazind Viral Hep - A, B, E EBV, CMV, Ischaeamic hep Budd Chiari Wilsons Post resection
2
Q
Causes of chronic liver failure
A
Viral B, C Alcoholic liver disease Non alcoholic steatohep Haemachromatosis Veno-occlusive disease Right side failure??
Autoimmune - hepatitis, PSC, PBS
3
Q
Defining trial of ALF
A
Coagulopathy
Jaundice (hyperbili)
Enceph (with raised ICP)
4
Q
Defining features of chronic failure/cirrhosis
A
Jaundice Ascites and SBP Variceal disease Encephalopathy WITHOUT raised ICP Hepatorenal synd Risk of HCC
5
Q
Define ALF
A
Rare
Life threatning disease
With risk of MOF and Death
Triad of
Encephalopathy
Coag
Jaundice
6
Q
Timing of ALF
A
Onset from jaundice to enceph
Hyperacute - <7 days
Acute 7-28 days
Sub acute 5-12 weeks
7
Q
Manifestations of ALF
A
Haemodynamic instability - high output vasodilation
AKI
Coagulapathy
Encephalopathy and coma (higher ammonia, higher risk of ICP)
Infection - sepsis
8
Q
Grade encephalopathy
A
West Haven system
Grades 1 -4
1 - Lack of awareness, euphoria, anxiety, impaired addition
2 - Lethargy, apathy, suble persona change, impaired subtraction, inapprpriate
3 - Somnolence —> semi stupour, confusion, disorientation, responds to voice
4 - Coma
9
Q
Management feaures
A
Specialist input —> transfer to liver centre Specific therapies —> NAC Supportive - ABC and RRT Manage enceph and ICP Manage coag Transplant
10
Q
Features of treating enceph and ICP
A
1) remove ammonia
Lactulose, LOLA, rifaxmine
RRT
2) manage oedema Temperature Sedation 30 degree head up nursing Loose ties Optimise CPP
11
Q
Features of coagulapthy management in ALF
A
Routine correction - afffects PT and therefore transplant decisions
Only if needing cover for procedures
12
Q
Contra indictations to liver transplant in ALF
A
Severe cerebral oedema
Rising vasopressor needs
Uncontrolled sepsis
Major psych co-morbidity
13
Q
Kings Criteria - Paracetamol
A
Ph< 7.3 (24 hours post admission AND following fluid resus)
OR
Grade 3 to 4 enceph
PT >100s
Cr>300
OR
Arterial lactate >3,5 at 4 hours
OR
>3 at 12 hours
14
Q
Kings Criteria for non paracetamol
A
PT>100
OR
3 of
PT>50 Non hep A/B aetiology Age <10 or >40 Bili > 300 Duration of jaudice prior to enceph > 7 days
15
Q
Why would chronic liver failure get into ITU
A
Variceal haemorrhage
Management of encephalopathy
Renal/metabolic dysfunction
Ascites and hepato renal syndrome
Extra hepatic —> sepsis, resp failure
16
Q
CVS changes in cirrhosis
A
Hyperdynamic circ —> low PVR, inc CO, decreased BP
Cirrhotic cardiomypoathy —> diastolic dysfunction
Alterations in hepatic/splanchnic flow —> hepatic resistance—> portal congestion, varices
Vascular changes to other organs - pulmonary vasodilation, VQ mismatch
Renal vasoconstriction —-> hepato renal
17
Q
Mortality scoring systems in CLD
A
Child-Pugh Score
MELD
UKELD
General systems - SOFA better than APACHE II in cirrhosis
CLIF - SOFA
18
Q
Features of Child Pugh score
A
Graded 1-3 per category
Bilirubin Albumin INR Ascites Enceph
A - 5-6
B - 7-9
C - >9
19
Q
Feautres of MELD
A
Creatinine, INR and Bilirubin
Placed in eqn.
UKELD , adds in sodium
20
Q
Why is renal dysfunction common in cirrhotivcd
A
Hypovolaemia —-> laxatives, blood loss from GI, sepsis, loop/spiro often used
Sepsis
Nephrotoxic agents - diuretics
HRS
21
Q
Types of HRS
A
Type 1 - Higher mortality —> two fold increase in Cr in 2 weeks
Type 2 - Ascites refractory to dieurtetic therapy
22
Q
Diagnosis of HRS
A
Cirrhosis with ascites
No improvement in creatinine after 2 days of diuretic withdrawel AND volume explansion
Albumin 1g/kg per day to a max of 100g
No shock
No current or recent nephrotoxics
Absence of parenchymasl kidney disease
(Proteinurial 4500mg/day, microhaematuria +/- abnormal renal US
23
Q
Management of renal dysfunction in HRS
A
Volume replacement HAS is colloid of choice 1g/kg load then 20-40g/day May bind cytokines Where sepsis predominates over HRS —> crystalloid
Vasoconstriction Terlipressin Splanchnic vasoconstriction —> renal perfusion increases and effective volume Avoid with high dose norad Can be given outside of ITU 1mg 4-6 hours
Non-responders - 50%
RRT as bridge to trasnsplant
Livefr support devices not in use
24
Q
Causes of ascites
A
Portal hypertension —> cirrhosis, Budd Chiari, Heart Failure
Hypoalbuminaemia —> nephrotic, malnutirion
Peritonal disesae —> infection, ovarian Ca, mesothelioma
25
Consequences of ascites
Pressure —> ACS
Resp comprimise
SBP
Hepatic hydrothorax
HRS
PAIN
26
Treatment of ascites
Sodium restriction
Furosemide and spiro
Paracentesis
Total abdominal paracent —> remove ALL fluid in a time frame
Limited paracent —> remove to an end point (e.g. IAP <20mmHg)
27
Benefits and risk of paracentesis
Benefits
Reduce intra abdominal pressure
Improved organ blood flow
Improved lung compliance
Patient comfort
```
Risk
Cutaenous or abdominal infection
Haemodyamic collapse
Renal dysfunction from low BP
Viscous perf
```
28
How long should an ascitic drain be left in
6 hours - infection risk
29
How much HAS after draining ascites
100mls of 20% for every 1-2 litres
30
Classification of hepatic encephalopathy (in terms of causes)
Not the ALF criteria
A - related to ALF
B - related to porto-systemic bypass
C - relates to cirrhosis
Difference from ALF is it happens for different reasons, and there is no rise in ICP
31
Causes of hep enceph in cirrhosis
```
Sepsis,
Constipation
Electroylte disturbance
GI bleed
Meds - benzos, propanolol (portal hypertension)
```
32
Management of hepatic enceph
Lactulose
Phosphate enemas
LOLA
RRT - indicated in hyperammonia
Gut -
Rifaximin
TIPPS —> reduce calibre
33
Indications for Liver trasnplanbt
```
ALF
HCC
Decompensated CLD
ACquired or chronic biliary disease
Metabolic disease
```
34
Peri-transplant issues
3 phases
Resection
Anhepatic phase
Reperfusion
Monitoring
Plasma lactate, normalises in first 6 hours
Monitor coag and gluconeogeneis (rising plasma glucose)
Immunosuppresion
iv Abx and antifungal
Peri op hydrocort/m-pred
Enteral early - tacrolimus, cyclosporin, azathioprine
If renal dysfunction - low dose tacrolimus and alternatives given basiluxamab
35
Post transplant complications
Primary Non Function
Failure to start enzymatic procceses
Transaminases dont normalise or rebound hyperbili, coag
Hep artery thrombosis
Doppler at 24 huors
If weak, triple phase CT
Revascularise, or regraft
Venous thrombosis
```
Biliary Issues
Bile leak/obstruction
Rising bili and ALP
ERCP??
Beware biliary peritonitis, drain/repair biliary
```
Sepsis
36
Define upper GI haemorrhage
Any bleed from the pharynx to the ligament of Treitz
37
Causes of non-variceal bleeds
H.pylori
Peptic ulcer disease
NSAIDs
```
NG tube trauma
Erosive tumour
Vascular ectasia
Mallery Weiss
Angiodysplasia
Dieulafoy lesions
```
38
Transfusion target in non variceal bleed
70g/dL reduced mort compared to 90
39
Features of non variceal bleed management
```
ABCDE
Early aggressive resus
Correct coag
Transfuse to 70
Risk stratify
PPI - Hong Kong
```
40
Name the risk stratifying scores in non variceal bleeds
Glascow Blatchford Score
Rockall (but needs endoscopy to be done to complete the score)
41
Feautres of Glascow Blatchford Score
```
On admission
Blood Urea
Hb (different scores for men and women)
Systolic BP
Other (pulse>100)
Melanea
Syncope
Liver disese
Heart failrue
```
42
Features of Rockall Score
Score 0-3
```
Age
Shock
Co-morbidities
Diagnosis (mallery, other, GI cancer)
Evidence of bleeding
```
43
Endotherapy options in non-variceal bleeds
Submucosal adrenlaine 1:10000
Biploar diathermy
Aluminium clipping
Haemostatic sprays
44
Differences between stress ulcers and peptic
Stress more likely to appear in gastric fundus
Bleeding is a diffuse ooze
Often related to reduced splanchnic flow
45
Risks or features associated with stress ulcer
```
Mechanical vent for more than 48 hours
Coagulopathy
MOF
History of GI bleeds
Trauma or burns
Steroids
Renal failure
```
46
Stress ulcer prophylaxis
Enteral feed early —> improves splanchnic flow
```
Drugs:
PPI
H2 antag
Sucrafate - protect mucosa
Antacids
```
PPI superior to H2, but mortality same
Sucrafate not as effective as either - second line
Sucrafate - inhibit digoxin and warfain, phenytoin
PPI - interact with anti-platelets
Risk of nosocomial pneumonia through acid suppresion (poor evidence)
Association between c.diff and acid suppresion
47
Compare non variceal to variceal treatments
Pre-endo, endoscopic, and resuce
Pre - Non variceal - iv PPI, variceal —> terlipressin and Abx
Endo - Adrenaline, diathermy, clips. VERSUS endoscopic band ligation and sclerotherapy
Rescue - Repeat, mesentertic angio and embolise, surgery
VERSUS repeat, Sangstaken Blackmore, Stent, TIPPS, transplant
48
Normal portal pressure in a non-cirrhosis
Less than 5mmHg
49
Portal hypertension value
Value at which haemorrhage occurs
Greater than 5mmHg
Greater than 10mmHg
50
Places where varices can form
```
Oesophagus —> retrograde splenic/long gastric vein flow
Gastric fungus
Rectum
Retroperitoneal
Abdominal wall
Liver bare area
```
51
Grade of varices
3 grades
1 - Small, disappear on insufflation of oesophagus
2 - between 2 and 3
3 - Large varices, occluding lumen
52
Management options of a variceal bleed
Antibiotics
Secondary infections
Prophylaxis reduces mortality
Cipro/ceftriaxone
Vasoactive
Terlipressin - constricts mesenteric arterioles
Sengstaken
Endoscopy
1 - no tx
2 and 3 beta blockade and band ligation
TIPPS
53
Features of risk of rebleeding in varices
High Child-Pugh score
Increasing portal pressure
High risk endoscopic features
54
Indications for TIPSS
Refractory variceal haemorrhage
Recurrent/refractory ascites
Hepatopulmonary syndrome
Hepatic hydrothorax
55
Things to do before TIPSS
Doppler of portal / biliary system
Relieve biliary obstruction before TIPSS
Echo - RH —> TIPPS causes increased RV preload
EEG - TIPPS can cause HE (not really in practise)
56
Describe a TIPPS
Venous access - RIJ
Catheter down SVC to hepatic vein
Portal vein identified —> needle directed from hep vein to portal vein
Guidewire and stent deployed
57
Contra-indications to TIPSS
Severe tricuspid regurgitation
Severe pulmonary hypertension
CCF
58
Complications of TIPPS
Access —> liver capsule rupture, biliary rupture and fistula, hepatic infarct
Stent —> thrombsis, migration
Shunt —> encephalopathy
59
Define diarrhoea
WHO —> 3 or more loose or watery stools a day
BGS —> 200g a day
Bristol - types 6 or 7
60
Types of diarrhoea
```
Osmotic
Can’t absorb osmotically active substances
Mg, Bile salt, lactulose
Malapbsorptiopn —> coeliac
STOP WITH STARVATION
```
Secretory
Increased secretion from mucosa
Decreased absorption
Infective diarrhoea and example —Cholera…secretes chloride
Inflammatory
Loss of muscles integrity
?bloody
IBD or infection — E. coli, shigella, salmonella
Dysmotile
After ileus for example
61
What is c.diff
Gram negative anaerobe, spore forming
62
Risk factors for c.diff
Use of Abx —> penicillins cephalosporins, clinicamycin
Long standing IBD
Intestinal surgery
PPI
Long hospital stay
Cancer, immunosuppresion, DM
63
Diagnosis of C.diff
PCR —> colonisation/carrier
CDT (toxin B) —> active infection
Colonoscopy —> pseudomembranes
64
Complications of c.diff
Bowel Perf
Toxic mega colon —> colonic dilation >7cm
```
Fulminant colitis
severe abdo pain, lactic acidosis
hypovolaemia
fever
raised WCC
```
65
Tx of c.diff
Metronidazole —> oral or iv
Vancomycin —-> oral only
Fidaxomicin —> non inferior to vanc but less SE
Faecal transplant
Surgery
colectomy
66
Other infective agents in diarrhoea
```
Inflammatory
E.coli
Shigella (cipro/ceftriaxone)
Campylobacter (cipro)
Salmonella (cipro)
```
Cholera (cipro/doxy)
Viral - Noro, rota, adeno ,CMV (ganciclovir)
Parasite - giardia, entamoeba (metronidiazole)
67
Causes of acute pancreatitis
```
Alcohol abuse
ERCP
Gallstones
Trauma
Metabolic - hyperlipids, hyper algae Mia
Drugs - Azathioprine, steroids
Infection -CMV, mumps
```
68
Diagnostic criteria of pacnreatitis
2 out of 3 of
Upper abdominal pain
Amylase of lipase >3 x upper range of normal
CT findings
69
Types of CT finding of pancreatitis
Acute interstitial oedematous 85%
Necrotic 15%
70
Severity class of pancreatitis Atlanta
Mild - no organ failure, no local/systemic complications
Mod - transient (<48hours) organ failure, OR complications
Severe - persistant organ failure or complication > 48 hours
71
What are the local complications of pancreatitis
Necrosis of the pancreas or peri-panic tissue
CT and FNAC
72
Systemic determinants of acute panc
Present and persistent organ failure
Sofa score >2
Transient —> less than 48 hours
73
New panc definitions building on Atlanta
Mild - absence of necrosis and organ failure
Mod - sterile necrosis+/- transient failure
Severe - infected necrosis +/- persistent failure
Critical - infected AND persistent failure
74
Pancreatitis scoring systems
```
Ransom Score
Glasgow Imrie Score
APACHE II
SOFA
Balthazar
CT severity Index
```
75
Describe Ransons score
Risk stratifies and predict mortality
Half on admission, half 24 hours later
```
Admission —> Age>55
AST>250
Glucose >11.2
WCC>16
LDH >350
```
```
24 hours —>. Fall in Hct>10%
PaO2<8
Base def >4
Fluid sequest > 6 litres
Urea rise >1.8
```
76
Ransons score indicates:
3 is severe
0-2: 2%
3-4 15%
5-6 40%
7-8 100%
77
What’s on the Glasgow Imrie Score
```
Age
PaO2
WCC
Calcium
Urea
LDH
Albumin
Glucose
```
3 or more —> critical care
78
Complications of pancreatitis
```
Local
Necrosis
Pseudocyst (>4 weeks)
Peri-pancreatic collections (early)
Pseudoaneurysm
Mesenterinc vein thrombus
```
Systemic —> exacerbation of co-existing disease
Organ failure —> ARDS, effusions, atectasis
Shock
AKI
Ileus, metabolic issues, ACS
79
Management principles of acute pancreatitist
Admit if Ranson >3
Supportive - fluid resus, analgesia, organ support (drip and suck no more)
Nutrition - no gut rest. Attempt NG feed. If not, try NJ. PN only for people who fail altogether
Feed early
Antibiotics - no. Only in infected necrosis after FNAC.
Probiotics - harmful, increased ischaemia
ERCP - gallstone pancreatitis
In presence of cholangitis
Cholestasis
Predicted severe
Do not do if mild.
80
Principles of necrotic pancreatitis, diag and management
Can be sterile or infected
Infected —> positive bacterial/fungal/culture on FNAC
Gas in pancreatic bed on imaging
Tx —> iv. Broad spec (carbapenem)
Wait for necrosis to wall off (4 weeks)
Percutaneous or endoscopic drainage OR minimally invasive necrosectomy Whipples…
81
Normal IAP
5-7mmHg
82
Define and grade IAH
Greater than 12mmHg
1 - 12-15
2 - 16-20
3 - 21-25
4 >25 mmHg
83
How to measure IAP
Direct - laparoscopic port
Indirect - ballon tipped catheter in stomach or bladder attached to transducer
Zero vesicular transducer to pubic symph
84
APP eqn
APP = MAP - IAP
85
Define ACS
IAP >20mmHg with associated organ failure +/- an APP<60
86
Causes of ACS
Surgical - haemorrhage, collection, ileus, large hernia, tight abdominal closure
Medical - peritoneal dialysis, intra-abdominal infection, pancreatitis, intestinal oedema
Trauma
Burns
Obesity
87
Consequences of ACS
Resp - splinting, reduced compliance, Adele tasks, decreased FRC. Hypoxaemia and infection
CVS - reduced venous return, SV and CO
Renal - reduced renal perf pressure at >15, anuria at >30
GI - hepatic dysfunction
Nervous - rising ICP
88
Measuring energy requirements
Indirect calorimetry - gold standard.
Calories on basis of oxygen consumption. No really done
Measure CO2 productio - needs stable conditions, and over feed overestimates expenditure
Estimation - Scholfied eqn, Harris Benedict eqns.
By weight - 25kcal/kg
89
Daily needs
Under 65 - 25kcal/kg, over 65, 20kcal/kg
Carbs - 60% of non protein calories
3.-4g/kg
Protein 1 to 1.5 g/kg
Increase for burns, trauma
Lipid 40% of noon protein
0.7-1.5G
Water 30mls/kg
```
Na 1-2mmol/kg
K 0.7-1
Ca 0.1
Mg 0.1
Phos 0.4
```
90
Pros and con of enteral nutrition
Cheaper
Easier to do
Lower risk of infection
Gut protective (maintains integrity)
BUT
Needs functioning GI tract
?VAP
Less reliable delivery of energy
91
Complications of PN
Access - needs a CVP and of that
Liver - hepatic steatosis, cholestasis, failure
Sepsis
Increased hyperglycaemia
92
EN versus PN evidence
CALORIES - no diff in 30 day mort. EN, more vomiting and hypo
93
Timing of nutrition
Early less than 48 hours, concenus is start early
