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Icm > Gastro & Heptology > Flashcards

Gastro & Heptology Flashcards

1
Q

What are the causes of acute liver failure ?

A 
Paracetamol overdose
Drug induced
Viral hepatitis (A BE)
Ischaemic hep + budd
Wilson’s
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2
Q

What are the causes of chronic liver failure ?

A 
Viral hepatitis (B C)
Alcoholic liver disease
Non alcoholic steatohepatitis (NASH)
Haemochromatosis
Autoimmune (psc/ pbs)
Right sided heart failure
Veno occlusive disease
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3
Q

Features of Acute liver failure

A

Coagulopathy
Encephalopathy
Hyperbilirubinaemia / jaundice

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4
Q

Features of chronic liver failure

A 
Hyperbilirubinaemia
Ascites
Varices
Encephalopathy without raised icp 
Hepatorenal syndrome
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5
Q

What is the difference between acute liver failure and acute on chronic ?

A

Acute liver failure is a rare life threatening disease with high risk of MOF and death. Acute on chronic describes deterioration or decompensation of chronic cirrhotic liver disease

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6
Q

What type of shock is associated with acute liver disease?

A

High cardiac output vasodilator shock

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7
Q

Why is there a high ammonia in ALF and how does in cause encephalopathy?

A

Amino acids are broken down in the gut and detoxified in the liver to ammonium which is Renaly excreted. In AlF there are raised levels of ammonia and freely cross the blood brain barrier. There it is converted to glutamine by glutamate dehydrogenase.
Glutamine is an intracellular oncotic ion leading to oedema and raised icp
>100 associated with severe encephalopathy

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8
Q

What is the west haven grading of hepatic encephalopathy?

A
  1. Lack of awareness, anxiety, low attention span
  2. Lethargy, not oriented to TIme place or person, inappropriate behaviour
  3. Somnolence, confusion, gross disorientation
  4. Coma
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9
Q

What are the contra indications to emergency liver transplant ?

A

Severe cerebral oedema
Rising vasopressor requirement uncontrolled sepsis
Psychiatric comorbidities

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10
Q

What are the cardiovascular changes in CLD and cirrhosis

A

Decrease peripheral resistance
Increase cardiac output
Hypotension
Cardiomyopathy with diastolic dysfunction
Increased intra hepatic resistance -> portal venous congestion
Splanchnic vasodilation

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11
Q

Outline the child Pugh score

A

5 indices
Bilirubin, albumin, INR, ascites and hepatic encephalopathy
1-3 points for each
A = 5-6 B = 7-9 c= >9

Mortality post operatively and in OPD increased with each score

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12
Q

What is the meld score and how is it used ?

A

Calculation involving creatinine bilirubin and INR giving a range of 1-40
Meld >15 transplant assessment
Uk meld has sodium in it

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13
Q

What is the mechanism of HRS ?

A

Inappropriate splanchnic vasodilation and reduction in renal perfusion
T1 creat >221 in 2 weeks with a 2 fold increase
T2 ascites refractory to diuretics
T1 has the highest 90 mort
International ascites club has a definition for hrs

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14
Q

What is the management of renal distinction in cld ?

A

HAS at 1g/kg the 20 g / day
Theoretically binds to nitric oxide
Use Terlipressin as a splanchnic vasoconstrictor at 1mg 416 hurly

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15
Q

What are the risks and benefits of paracentesis for ascites

A 
Benefits
Reduction in intra abdominal hTN
Improved renal splenic and hepatic blood flow 
Improved lung Compliance
Comfort
Risks
Infection
Haemodynamic collapse 
Haemorrhage 
Perf
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16
Q

What dose of Has given in paracentesis ?

A

100mls of 20% for 1-2 l

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17
Q

How can hepatic encephalopathy be classified ?

A 
A= acute liver failure
B= Porto systemic bypass
C = cirrhosis is

Ishen guidelines

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18
Q

What are the management strategies for hepatic encephalopathy?

A

Lower ammonia

  • lactulose
  • phosphate enema
  • branch chain amino acids
  • rrt

Gut decontamination

  • Rifaximin
  • tipss
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19
Q

What is the definition of Intra abdominal hypertension

A

Sustained or repeated IAP measurement > 12

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20
Q

What is the definition of intra abdominal compartment syndrome

A

Sustained IAP > 20 associated with new organ dysfunction

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21
Q

How can you measure intra abdominal pressure

A

Direct - need puncture directly into the abdomen

Indirect - via a urinary catheter in the bladder

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22
Q

What is a cause of hypochloraemic alkalosis

A

Gastric outlet obstruction leading to vomiting and the loss of hydrogen and chloride ions

Diuretic therapy

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23
Q

2 commonest causes of gastric outlet obstruction

A

Gastric ca

Peptic ulcer disease

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24
Q

Urinary changes is gastric outlet obstruction

A

High ph of the urine due to renal bicarbonate loss

Paradoxical acuduria- hydrogen ions are exchanged for sodium ions to maintain the circulating volume

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25
Q

How to reduce the risk of refeeding

A

IV thiamine
Correct k, phosphate, mg
Start feed at no more than 50%
Monitoring

26
Q

Benign causes pneumotosis interstialis

A

Pulmonary: COPd, asthma, CF, high peep

Intestinal: pyloric stenosis, pseudo obstruction , DU, crohns

Iatrogenic: NJ, surgical anastomoses , barium enema

Medication: steroids, lactulose , chemo

Organ transplant

27
Q

Life threatening causes of pneumotosis interstialis

A 
Intestinal ischaemia
Mesenteric vascular disease
Enteritis 
Colitis
Intestinal obstruction 
Ingestion corrosive agent 
Toxic mega colon 
Trauma 
BMT
28
Q

Where alt produced

A

Liver
Skeletal muscle
Kidney
Heart

29
Q

Cholestatic alp picture

A

Alp x 2 normal

Alt: alp < 2

30
Q

Hepatocellular picture

A

Alt x 3

Alt:alp > 5

31
Q

Findings on LFTs suggestive of chronic liver disease vs cirrhosis

A

Alt> ast chronic

AST> alt cirrhosis

32
Q

What is the atlanta criteria

A

Mild - no organ failure
Moderate - transient <48 hours organ failure
Severe - > 48hrs organ failure

33
Q

What ranson score is suggestive of severe pancreatitis and what are the conponents

A

> 3

Age/ ast/ glucose / wcc / ldh

34
Q

Define intravdominal hypertension

And compartment syndrome

A

Intra abdominal HTN 12

Intra abdominal compartment syndrome 20

35
Q

How do you set up an intraabdominal pressure monitor

A 
Foley catheter
50 mls saline into bladder
X clamp distal to asp port 
Pressure transducer through asp port.
Pubic symphysis is the zero
36
Q

Radiological findings of pseudo obstruction

A

Dilation of the large bowel without evidence of an abrupt transition point or mechanically obstructing lesion

37
Q

When Is air in the bowel benign

A

Can be an incidental finding when the patient is asymptomatic and is only in the colic wall.

Pulmonary disease 
Scleroderma 
Lupus
AIDS
Intestinal inflammation 
Procedures
Steroids lactulose sorbitol
38
Q

Life threatening causes of air in bowel wall

A 
Intenstinal ischaemia 
Obstruction 
Colitis
Toxic caustic ingestion
Toxic mega colon
Transplant
39
Q

Dimensions for large and small bowel obstruction

A

Small bowel > 3cm

Large bowel > 6cm, caecum 9

40
Q

What does terlipressin do

A

Splanchnic vasoconstrictor

Decrease portal venous blood flow

41
Q

What does tipps stand for and do

A

Transjugular intrahepatic portosystemic shunt

Diverts blood from the portal vein into the venous system

42
Q

What is the child’s Pugh for and what is within it

A

Prognostication in cirrhosis

Bilirubin 
Albumin 
Inr
Ascites 
Hepatic encephalopathy

C= 65% 1 yr

43
Q

What is the maddreys for and what is within it

A

Prognostication in alk hep

Pt and bili

> 32 has 35-45% 30 day mortality

44
Q

What is the meld score for and what is within it

A

Stratify for end stage liver disease for transplant

Dialysis
Creatinine 
Bili 
Inr
Sodium
45
Q

What is the o’gradys classification

A

Hyperacute <7 days
Acute 7-28 days
Subacute 1 - 3 month

46
Q

What is the triad of acute liver failure

A

Jaundice
Coagulopathy
Encephalopathy

47
Q

Define cirrhosis

A

Progressive hepatic fibrosis with distortion of the liver architecture and formation of nodules

48
Q

Define decompensated liver disease

A 
Developement of one or more complications of cirrhosis 
Ascites
Encephalopathy 
GI bleed
Bacterial infection
49
Q

Define acute on chronic liver failure

A

Acute decompensation
With organ failure ( clif- sofa)
High predicted 28 day mortality

50
Q

What does alt> ast mean

A

Chronic liver disease

51
Q

What does alt> ast mean

A

Cirrhosis or alk hep

52
Q

What lfts suggest hepatocellular

A

10x alt

3x alp

53
Q

What LFTs suggest cholesstatic picture

A

Alp raised

Alt mild increase

54
Q

What does unconjugated bilirubin suggest

A

Pre-hepatic cause

55
Q

Presentation of short bowel syndrome

A

Ileum - vit b12, bile acids and fat soluble (A D E K)

Distal ileum- secretes gastrin secretin (gastric acid control) and protease and carbohydrase (carb / prot digenstion)

Ileocoecal valve- bacterial overgrowth

Osteoporosis - vit d absorption

56
Q

How short does the bowel need to be for short bowel syndrome to occur

A

Leas than 2 metres

57
Q

Post splenectomy care

A

Immunisations

  • pneumococcal
  • Hib
  • meningococcal
  • influenza

Prophylactic abx

  • amoxicillin
  • 6 month post for 3 yrs
58
Q

What are the components of SDD

A
  1. Orobase: non absorbable antibiotics (polynixinB tobramycin ampho B) PTA
  2. Systemic prophylaxis with cefotaxime to prevent respiratory infections caused by comensals
  3. Optimal hygiene
  4. Regular throat and faceal cultures for monitoring
59
Q

Benefits of SDD

A

Aim to reduce the risk of nocisomal infections

Target common aerobic gram negative bacilli

60
Q

What is normal intra abdominal pressure

A

5-7

61
Q

What is intra abdominal HTN pressure

A

12

62
Q

What is intra abdominal compartment syndrome pressure

A

20

With end organ failure

Icm (16 decks)

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