Gastro/Hep

Question 1

Hepatic failure

Answer 1

SBP = polymorphonuclear cells > 250
Mx - drain and Abx

Renal failure in chronic liver failure

• Pre-renal - hypoperfusion, sepsis, cardiac failure, hepatic failure
• Intrinsic renal - nephrotoxic drugs
• Post renal - renal outflow obstruction
• HRS

Question 2

HRS

Answer 2

Pre-renal AKI not responsive to fluid therapy.
Abnormal auto regulation with renal vasoconstriction and dilatation of splanchnic vessels.
Type 1 = rapidly progressive
Type 2 = indolent course

Dx criteria:
1 - Cirrhosis with ascites
2 - Creat > 133
3 - No improvement after withdrawal of diuretics and vol expansion alb for 2 days
4 - Absence of shock
5 - Absence of nephrotoxins
6 - Absence of parenchymal disease

Mx - Albumin and terlipressin, consider TIPSS, liver tx

Question 3

Alcoholic Hep

Answer 3

Progressive liver inflammation and injury due to heavy alcohol intake.
Hx of sig alcohol intake, fever and worsening LFTs

Mx - supportive, steroids and abstinence

Question 4

Non-paracetamol King’s criteria

Answer 4

INR > 6.5

Or any 3 of:

Age < 10 or > 40
Non-A, non-B hepatitis or drug reaction
Jaundice to encephalopathy > 7 day
INR > 3.5
Bili > 300

Question 5

Encephalopathy

Answer 5

1 - lack of awareness, shortened attention
2 - disorientation, lethargy or apathy
3 - somnolence, stupor, responsive to stimuli
4 - coma

Question 6

Chronic liver failure

Answer 6

Diff between acute liver failure and decomp chronic disease:
Hx, clinical (spider naevi, palmar erythema, gynaecomastia) blood tests, imaging (small contracted liver, portal HTN)

ICU admission:
Variceal bleeding, encephalopathy, AKI, sepsis, alc hepatitis

Decompensation:
GI bleed, infection inc SBP, drugs, alc hepatitis, dehydration, constipation, HCC

Mx:
ABCDE
Treat triggers - infection, GI bleeding
Organ support - coag
Lactulose
Pabrinex 
Diuretics for ascities

Question 7

TIPSS

Answer 7

Transjugular intrahepatic portosystemic shunt:
Communication between to the inflow of the portal vein and outflow of the hepatic vein
Reduces pressure difference between portal and systemic systems
Can precipitate hep encephalopathy

Complications:
Puncture site - bleeding, liver injury, bile duct injury
Hep encephalopathy in 25%
Shunt thrombosis 
Fluid overload

Question 8

Child-Pugh Score

Answer 8

Encephalopathy 
Ascities
Bilirubin
Albumin 
INR

Scored 1-3

A, B and C

Question 9

UK-MELD

Answer 9

Bilirubin
Creat
INR

Aid selection of patients for transplant

Question 10

Gastroparesis

Answer 10

Gastroparesis - Reduced stomach emptying
Ileus - hypomotility of small intestine not due to anatomical obstruction
Acute colonic pseudoobstruction -

Rule out other causes.

Causes:
1 - Drugs: Opioids, CCB, anti-Parkinson’s meds, muscle relaxants
2- Metabolic/electrolyte: Low K, low Na, low Mg, high BMs, low thyroid
3- Abdominal pathology: Surgery, peritonitis, pancreatitis
4 - Neuro; stroke

Gastroparesis Mx: metoclopramide and erythromycin
Ileus: Limit opioids, enteral naloxone
Colonic pseudoobstruction: Review meds, laxatives and neostigmine

All: early feeding, early mobilisation, good pain control, fluid balance, electrolyte correction