Gastro Flashcards
What are the indications for liver transplant?
Survival > 50% 5yrs post-transplant
- MELD > 15
- LIver disease with > 50% mortality at 2yrs if not transplanted
- Diuretic-resistant ascites
- Recurrent hepatic encephalopathy
- Recurrent SBP
- Recurrent or persistent GI haemorrhage
- Intractable cholangitis
- Hepatopulmonary syndrome
- Portopulmonary HTN
- Metabolic syndromes (with severe or life-threatening symptoms) that are curable with liver transplantation (eg. familial amyloidosis, urea cycle disorders, oxalosis)
- Polycystic liver disease with severe or life-threatening symptoms
- Intractable itch secondary to cholestatic liver disease
- Hepatoblastoma
What are the contraindications to liver transplantation?
Active illicit substance misuse AIDS Extrahepatic malignancy Uncontrolled sepsis Extrahepatic organ failure (lungs, heart). Pulmonary pressure > 50mmHg absolute contraindication. Splanchnic thrombosis extending to SMA
What are the management principles in cirrhosis?
- Weight loss if overweight => decreased mortality and HCC risk
- Late evening high protein meal => reduced muscular catabolism
- Coffee => 2 cups daily reduced all-cause mortality, fibrosis and HCC
- Dark chocolate and Vit C => reduces post-prandial rise in HPVG
- No EtOH. Baclofen if alcoholic + cirrhotic.
- Smoking cessation => less fibrosis in Hep C, NASH, PBC. Improved post-transplant morbidity and mortality.
- Vaccination: Hep A, Hep B, influenza, pneumococcus as early as possible
Portal HTN
- Defined as HVPG > 5mmHg. Varices develop when HVPG > 10mmHg. Bleeding if HVPG > 12mmHg
- SAAG ≥ 11 also defines portal HTN
- Na restriction to <2g/day
- Spironolactone 100mg/d (max 400mg/d) +/- frusemide 40mg/d (max 160mg/d)
- Non-selective beta blockers (propranolol or carvedilol) to target BP<60. Ensure HR>50 and systolic BP>90. Also reduces incidence of spontaneous bacterial peritonitis. Contraindicated if refractory ascites, SBP, severe alcoholic hepatitis, or BP < 100 systolic.
- Midodrine may increase U/O, urinary Na excretion, and MAP in those with stable hypotension.
- Fluid restrict if Na < 120 (intake < urine output)
Varices
- Banding if variceal bleeding
- TIPSS if recurrent GI bleeds despite banding
Ascites
- Large volume paracentesis with 8g/L albumin IV (20g in 100mL of 20%) when drainage > 5L
Spontaneous bacterial peritonitis phrophylaxis
- Secondary prophylaxis if previous SBP.
- Bactrim DS 1 daily 1st line, norfloxacin 2nd line
- Primary prophylaxis if ascites protein < 15/g AND renal impairment (Cr ≥ 110 or Ur ≥ 8.9 or Na ≤ 130) or liver failure (Child-Pugh ≥ 9 and bili ≥ 50)
Encephalopathy
- Lactulose and rifaximin
Meds
- Avoid NSAIDs, ACEIs, aminoglycosides (renal impairment).
- PPIs may increase risk of SBP.
- Antihypertensives should cease (increased survival if systolic BP>82)
- Limit paracetamol to 2g/d
- If sedatives are necessary, use either loraz or oxaz (short acting); or trazodone 100mg nocte.
- Use statins in NAFLD - mortality benefit
Transplantation discussion
Consider when MELD ≥ 17
Which patients with chronic HBV infection should be treated?
- Adults with immune-active CHB (HBeAg- or HBeAg+), defined by ALT >2 times ULN or evidence of significant histological disease and HBV DNA >2000 IU/mL (HBeAg negative) or >20,000 IU/mL (HBeAg positive)
- Persons with immune-active CHB and cirrhosis if HBV DNA >2000 IU/mL, regardless of ALT level
- Persons ˃40 years with normal ALT and elevated HBV DNA (≥1,000,000 IU/mL) and liver biopsy showing significant necroinflammation or fibrosis
Wha are the stages of chronic HBV infection?
Immune tolerant => immune active => inactive carrier => immune escape/reactivation
Which urinary markers can be used to distinguish between hepatorenal syndrome and ATN?
NGAL and IL-18 (elevated in ATN)
What are the pharmacological treatment options in hepatorenal syndrome?
Albumin 1g/kg/d + terlipression OR
Albumin 1g/kg/d + octreotide + midodrine
CRRT
Liver-kidney transplant
What do the MELD and UKELD scores predict?
3 month and 1 year mortality respectively
What is the initial diuretic regime in cirrhosis with ascites?
Spironolactone 100mg daily + frusemide 40mg daily
Combined Rx better than sequential Rx
What assessment tools are available in Crohn’s Disease?
CDAI - Crohn’s Disease Activity Index (symptomatic)
CDEIS - Crohn’s Disease Endoscopic Index of Severity (inflammation assessment)
CRP and faecal calprotectin - inflammation
PROSPECT - web-based tool to predict risk of developing CD-related complications. Most important parameters are 1) disease location, 2) depth of lesions, 3) disease extent, and 4) young age of pt.
Treat early with biologics - better outcomes
How do you decide between biologic agents in Crohn’s Disease?
Anti-TNF
- Best results on mucosal healing
- Preferred in spondyloarthropathies or uveitis
- If deep fistulising disease, use anti-TNF + DMARD
Anti-integrin (vedolizumab)
- At 6-12 months, mucosal healing very good
- Preferred in concurrent skin disorders
Anti-IL12/23 (ustekinumab)
- Preferred in concurrent psoriasis
What conditions are associated with coeliac disease?
- Aphthous ulcers and angular cheilitis
- Dry skin, hair and nails
- Dental problems: thin enamel
- Neurological: ataxia, polyneuropathy, epilepsy
- Cardiac: pericarditis, cardiomopathy
- Fatty liver
- NHL, particularly affecting the intestines
- Dermatitis herpetiformis
- Osteoporosis
- IgA deficiency
- Hyposplenism
- Recurrent miscarriages
Where is Fibroscan validated? What value excludes cirrhosis?
Validated in Hep C, pre-treatment
Elastography < 12.5kPa => excludes cirrhosis
What APRI score excludes cirrhosis?
APRI < 1.0 => not cirrhosis
What is the main micronutrient deficiency in gastric bypass patients?
Iron deficiency
Which serum parameters are low in protein-losing gastroenteropathy?
Albumin Gamma globulins Lymphocytes A1AT Fibrinogen Cholesterol Caeruloplasmin Transferrin Retinol - Vit A Vit D Alpha-tocopherol - Vit E PIVKA-II (proteins induced in vitamin K absence)
How is protein-losing gastroenteropathy diagnosed?
Elevated stool A1AT clearance
Alpha 1-antitrypsin clearance = (stool volume) x (stool alpha 1-antitrypsin)/ (serum alpha-1 antitrypsin)
Intestinal lymphangiectasis (with protein loss) is associated with which conditions?
Secondary to IBD Turner's syndrome NF1 Yellow nail syndrome Noonan's syndrome Klippel–Trenaunay and Hennekam syndromes
What are the treatment options in Wilson’s disease?
- Lifelong penicillamine (given with pyridoxine)
- Tetrathiomolybdate with zinc salts in those with neurological symptoms
- TIPS in decompensated liver failure
Which PSC patients are most likely to develop cholangiocarcinoma?
Those with PSC and UC (23% of patients).
Very unlikely in PSC + Crohn’s.
How can EtOH intake be quantified?
AUDIT-C ≥3 for women or ≥4 for men
- How often do you drink EtOH
- How many standard drinks of EtOH would you drink on an average day?
- How often do you drink 6 or more standard drinks in a day?
SADQ
- Designs by WHO to measure EtOH dependence
Which patients should be considered for residential-assisted or inpatient withdrawal?
- More than 30 units of EtOH daily
- SADQ>30
- Epilepsy or withdrawal-related seizures or delirium tremens during previous assisted withdrawal programs
- Needs concurrent withdrawal from alcohol and benzodiazepines
- Regularly drinks 15–20 units of alcohol a day and has psychiatric or physical comorbidities (eg. chronic severe depression, psychosis, malnutrition, CCF, unstable angina, chronic liver disease) or a learning disability or cognitive impairment
What are the primary initial options in moderate to severe EtOH dependence?
- Acamprosate or naltrexone (C/I in pregnancy, or severe hepatic or renal disease)
- CBT focusing specifically on EtOH misuse
