Gastro Flashcards
Why do you bleed in liver disease?
- Reduced number and function of platelets
- Increased fibrinolytis
- Clotting factors defective synthesis
- increase in factor 8 for some reason but decrease in all the others especially factor seven which has a really short half life
Leads to prolonged PT - aptt and thrombin clotting time may be long too THE MIXING STUDY FOR APTT WILL CORRECT THIS TOTALLY
How would you differentiate urine of hepatorenal syndrome from ATN?
Urine sodium low (less than 20) and is hyperosmolar compared with ATN
What does OLT stand for?
Orthotopic liver transplant
What is terlipressin and how does it work?
Long acting vasopressin analogue
Mediates vasoconstriction by activation of the V1 receptor
Preferentially expressed on vascular smooth muscle cells within the splanchnic bed and thus reverses vasodilation
What bugs are responsible for SBP?
50% will be culture positive
50% gram pos
50% gram neg
** should be a trigger for referral for transplant- 1 year mortality is 40% after the first episode.
What was the study that showed effect of terlipressin in HRT?
OT-0401 Sanyal 2008 Terlipressin + albumin vs albumin alone Higher chance of reversal in tx group Optimal if treated for three days No difference in overall or transplant free survival
What is the cause of acute liver failure is the AST:ALT ratio is greater than 2.2 and ALP:bilirubin less than 4?
100% specific for Wilson disease in acute liver failure
How does HDV work?
Needs coinfection with HBV for transmission.
If get both B and D at same time- higher mortality, worse acute hepatitis.
HDV presence will supress HBV load in chronic infection
Treatment is pegIFN for 48 weeks.
How does HEV work?
RNA virus, genotype 3 most common
Diagnose via Ab however in the immunosupressed need to directly look for RNA
Can have chronic infection in immunocompromised patient.
Get from food, esp pig meat.
What evidence based therapy is there for fatty liver disease?
Weight loss 7%
Mediterranean diet
Which is worse for HCC risk in the setting of cirrhosis?
HCC/HBV/alcoholic cirrhosis?
HBV and alcoholic cirrhosis- 3-4% per year as opposed to 2% per year
What is the only oral chemo for HCC?
Sorafenib
- lots of s/e and poorly tolerated eg hand foot skin reaction, diarrhoea
- candidates if Child Pugh A but not for surgery, transplant or ablative therapy
- Improves survival and progression free survival
- Inhibits multiple tyrosine kinases and Raf kinases
Which SNp makes you more prone to developing fibrosis in alcoholic liver disease?
PNPLA3
Not sure what the gene normally does!
Mallory hyaline what significance on hist?
Red material in cells in clouds…
most often seen with chronic alcoholism
Remember that fatty liver and alcoholic fatty liver look just the same.
Acute alcoholic hepatitis histo?
Mallory's hyaline Neutrophils Hepatocyte necrosis Collagen deposition Fatty change
What are the only two therapies shown to be of benefit in alcoholic hepatitis in selected cases?
Corticosteroids
Pentoxifylline- competitive nonselective phosphodiesterase inhibitor
When would you use Steroids or pentoxifilline in alcoholic hepatitis.
If MDF is 32 or more or MELD is 18 or more or presence HE
–>prednisolone or if steroids C/I or early renal failure penoxifilline
Otherwise, nutritional support and close follow up
What is the half life of ALT?
24 hours- so if more gradual decrease, then potentially ongoing injury.
Explain paracetamol metabolism-
Mostly metabolised to inactive glucuronide or sulphate conjugates and excreted in urine.
The 10% remainder is metabolised via P-450 producing NAPQI- if this is bound by glutathione can be excreted in the urine. Free= toxic.
What are some rules of thumb for panadol overdose and NAC?
Less than 1 hour: activated charcoal and measure level within 4-8 hours of ingestion
1-8 hours: measure level and plot on nomogram
Over 8 hours: commence NAC then get panadol and ALT levels. If ALT not normal at the end of the NAC infusion then KEEP GOING UNTIL panadol level undetectable and ST AND ALT are normal or trending well.
If over 24 hours post infusion or under treatment line and ALT is normal then stop NAC
Watch for hypos and do not treat hyperglycaemia unless very high. Do not give FFP unless active bleeding. Vit K does not normally work.
Kings college criteria for PANADOL
pH less than 7.3
OR all of:
INR over 6.5
encephalopathic 3-4
Creatinine over 300
Kings college criteria NOT panadol
3 of:
INR over 6.5
Age under 10 or over 40
Caused by hep C, idiosyncratic reaction, halothane
Jaundice more than 7 days before encephalopathy
INR over 3.5
Bili over 300
Most high risk drug induced cholestasis
Anti-androgens (CPA, flutamide)
Recommendations in chronic liver disease mx
- nutritional
- coagulopathy
- ascites
- renal dysfunction
- portosystemic encephalopathy
- pulmonary hepatic vascular disorders
Nutritional: maintain adequate protein intake 1-1.5 g/kg
Coagulopathy: vit k supplementation, FFp transfusions, IV cryoprecipitate, IV recomb factor VIIa, plt transfusions
Ascites: paracentesis, salt restrict less than 2g, spiro/frusemide, fluid restrict IF Na under 120, avoid saline, avoid NSAIDs
Renal: avoid nephrotoxins, albumin infusion if over 5L paracentesis
Encephalop: avoid sedatives and opiates, lactulose titrated, nonabsorbable oral abx, restrict protein
Pulmonary: supportive care, supplemental oxygen
