Gastro/Hep OSCE

Question 1

Hepatic failure

Answer 1

SBP = polymorphonuclear cells > 250Mx - drain and AbxRenal 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 ascites2 - Creat > 1333 - No improvement after withdrawal of diuretics and vol expansion alb for 2 days4 - Absence of shock5 - Absence of nephrotoxins6 - 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 LFTsMx - supportive, steroids and abstinence

Question 4

Non-paracetamol King’s criteria

Answer 4

INR > 6.5 Or any 3 of:

Age < 10 or > 40Non-A, non-B hepatitis or drug reactionJaundice to encephalopathy > 7 dayINR > 3.5Bili > 300

Question 5

Encephalopathy

Answer 5

1 - lack of awareness, shortened attention2 - disorientation, lethargy or apathy 3 - somnolence, stupor, responsive to stimuli4 - 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 hepatitisDecompensation:GI bleed, infection inc SBP, drugs, alc hepatitis, dehydration, constipation, HCC

Mx:ABCDETreat triggers - infection, GI bleedingOrgan support - coagLactulosePabrinex 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 veinReduces pressure difference between portal and systemic systemsCan precipitate hep encephalopathy

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

Question 8

Child-Pugh Score

Answer 8

Encephalopathy AscitiesBilirubinAlbumin INR

Scored 1-3A, B and C

Question 9

UK-MELD

Answer 9

Bilirubin Creat INRAid selection of patients for transplant

Question 10

Gastroparesis

Answer 10

Gastroparesis - Reduced stomach emptyingIleus - hypomotility of small intestine not due to anatomical obstructionAcute colonic pseudoobstruction - Rule out other causes.Causes:1 - Drugs: Opioids, CCB, anti-Parkinson’s meds, muscle relaxants2- Metabolic/electrolyte: Low K, low Na, low Mg, high BMs, low thyroid3- Abdominal pathology: Surgery, peritonitis, pancreatitis4 - Neuro; strokeGastroparesis Mx: metoclopramide and erythromycin Ileus: Limit opioids, enteral naloxoneColonic pseudoobstruction: Review meds, laxatives and neostigmineAll: early feeding, early mobilisation, good pain control, fluid balance, electrolyte correction