Gastro & Heptology Flashcards by rachel saund

What are the causes of acute liver failure ?

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

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What are the causes of chronic liver failure ?

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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Features of Acute liver failure

Coagulopathy
Encephalopathy
Hyperbilirubinaemia / jaundice

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Features of chronic liver failure

Hyperbilirubinaemia
Ascites
Varices
Encephalopathy without raised icp 
Hepatorenal syndrome

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

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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What type of shock is associated with acute liver disease?

High cardiac output vasodilator shock

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

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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What is the west haven grading of hepatic encephalopathy?

Lack of awareness, anxiety, low attention span
Lethargy, not oriented to TIme place or person, inappropriate behaviour
Somnolence, confusion, gross disorientation
Coma

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What are the contra indications to emergency liver transplant ?

Severe cerebral oedema
Rising vasopressor requirement uncontrolled sepsis
Psychiatric comorbidities

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What are the cardiovascular changes in CLD and cirrhosis

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

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Outline the child Pugh score

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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What is the meld score and how is it used ?

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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What is the mechanism of HRS ?

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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What is the management of renal distinction in cld ?

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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What are the risks and benefits of paracentesis for ascites

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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What dose of Has given in paracentesis ?

100mls of 20% for 1-2 l

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How can hepatic encephalopathy be classified ?

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

Ishen guidelines

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What are the management strategies for hepatic encephalopathy?

Lower ammonia

lactulose
phosphate enema
branch chain amino acids
rrt

Gut decontamination

Rifaximin
tipss

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What is the definition of Intra abdominal hypertension

Sustained or repeated IAP measurement > 12

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What is the definition of intra abdominal compartment syndrome

Sustained IAP > 20 associated with new organ dysfunction

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How can you measure intra abdominal pressure

Direct - need puncture directly into the abdomen

Indirect - via a urinary catheter in the bladder

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What is a cause of hypochloraemic alkalosis

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

Diuretic therapy

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2 commonest causes of gastric outlet obstruction

Gastric ca

Peptic ulcer disease

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Urinary changes is gastric outlet obstruction

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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How to reduce the risk of refeeding

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

Benign causes pneumotosis interstialis

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

Life threatening causes of pneumotosis interstialis

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

Where alt produced

Liver Skeletal muscle Kidney Heart

Cholestatic alp picture

Alp x 2 normal | Alt: alp < 2

Hepatocellular picture

Alt x 3 | Alt:alp > 5

Findings on LFTs suggestive of chronic liver disease vs cirrhosis

Alt> ast chronic | AST> alt cirrhosis

What is the atlanta criteria

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

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

>3 | Age/ ast/ glucose / wcc / ldh

Define intravdominal hypertension | And compartment syndrome

Intra abdominal HTN 12 | Intra abdominal compartment syndrome 20

How do you set up an intraabdominal pressure monitor

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

Radiological findings of pseudo obstruction

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

When Is air in the bowel benign

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 ```

Life threatening causes of air in bowel wall

``` Intenstinal ischaemia Obstruction Colitis Toxic caustic ingestion Toxic mega colon Transplant ```

Dimensions for large and small bowel obstruction

Small bowel > 3cm | Large bowel > 6cm, caecum 9

What does terlipressin do

Splanchnic vasoconstrictor | Decrease portal venous blood flow

What does tipps stand for and do

Transjugular intrahepatic portosystemic shunt Diverts blood from the portal vein into the venous system

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

Prognostication in cirrhosis ``` Bilirubin Albumin Inr Ascites Hepatic encephalopathy ``` C= 65% 1 yr

What is the maddreys for and what is within it

Prognostication in alk hep Pt and bili > 32 has 35-45% 30 day mortality

What is the meld score for and what is within it

Stratify for end stage liver disease for transplant ``` Dialysis Creatinine Bili Inr Sodium ```

What is the o’gradys classification

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

What is the triad of acute liver failure

Jaundice Coagulopathy Encephalopathy

Define cirrhosis

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

Define decompensated liver disease

``` Developement of one or more complications of cirrhosis Ascites Encephalopathy GI bleed Bacterial infection ```

Define acute on chronic liver failure

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

What does alt> ast mean

Chronic liver disease

What does alt> ast mean

Cirrhosis or alk hep

What lfts suggest hepatocellular

10x alt | 3x alp

What LFTs suggest cholesstatic picture

Alp raised | Alt mild increase

What does unconjugated bilirubin suggest

Pre-hepatic cause

Presentation of short bowel syndrome

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

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

Leas than 2 metres

Post splenectomy care

Immunisations - pneumococcal - Hib - meningococcal - influenza Prophylactic abx - amoxicillin - 6 month post for 3 yrs

What are the components of SDD

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

Benefits of SDD

Aim to reduce the risk of nocisomal infections Target common aerobic gram negative bacilli

What is normal intra abdominal pressure

5-7

What is intra abdominal HTN pressure

What is intra abdominal compartment syndrome pressure

20 | With end organ failure