Gastro - OSCE - Liver Flashcards
How do you do an ascitic tap
Consent if possible
Use percussion or ultrasound to find best position
Position supine or lateral decubitus
Asepsis - sterile gown, gloves, facemask, chlorhex to skin
Drape and US probe cover
Infiltrate skin with lignocaine
20g needle on a 20ml syringe perpendicular to skin, aspirate
40mls for tests
Tests to do with ascites
Cell count and differential MC&C LDH Albumin Amylose Glucose Cytology
SBP diagnosis on ascites
Polymorphonuclear cells (PMN) >250 PMN/mm3
How would TB look in ascites
Large lymphocyte count instead of PMN
Once SBP has been diagnosed, what other Ix might you do
Renal biochemistry
Abdo ultrasound
Causes of an AKI in liver disease
Pre-renal - hypoperfusion, sepsis, cardiac and hepatic failure
Renal - nephrotoxic drugs, intirinsic disease
Post - renal obstruction
HRS
Mortality of type 1 HRS
90%
What features suggest synthetic failure
Low albumin
Raised INR
Management of refractory ascites
Sodium restriction High dose furosemide and spironolactone Beta blockers for portal hypertension TIPS Liver transplant
Triad of acute liver failure
Jaundice
Encephalopathy
Coagulapathy
Classifcation of acute liver failure
O Grady - Interval from jaundice to encephalopathy:
Hyper acute - less than 7 days
Acute 1 to 4 weeks
Sub acute 4 weeks 6 months
Differentials of acute liver failure
Drug induced - paracetamol
Viral Hep ABC,E
Alcoholic Hep
Auto immune hep
Miscellaneous- ischaemic hep, Budd Chiari, HELLP, fatty liver, Wilsons
Budd chiari presentation
Abdo pain
Ascites
Liver enlargement
Due to hepatic venous obstruction
Investigations of acute liver failure
FBC, U&E, LFT CLOTTING STUDIES Paracetamol/salicylate level GLUCOSE Lactate
ABG (lac/gluc)
Auto-immune screen - anti smooth muscle/mitochondrial
Vita hep screening
Ammonia
Treatment of paracetamol overdose
ABCDE
Establish time of ingestion
Start NAC if level is above treatment line
Correct hypoglycaemia - dextrose
Grading of encephalopathy
West Haven Scale
0 - Subclinical. Normal but minimal change in memory and concentration
1 - mild confusion, low attention, slow to do tasks
2 - Drowsiness, lethargy, gross deficit in task. Persona change, disorientated
3 - Somnolent but reusable, can’t do mental task, confusion, aggression
4 - coma, posturing
Managing cerebral oedema in encephalopathy
Head up tilt Loose ties Normocapnoea Maintain CPP 90 ICP monitor Normoglycaemia ?refer
Causes of Upper GI bleed
Peptic ulcer (gastro/duodenal)
Oesophagitis, gastritis, duodenitis
Varices
Mallory Weiss
Angiodysplasia
Aorta-enteric fistula
Malignancy (oesophagus/gastric)
History and examination in cirrhosis plus Upper GI bleed
History - confirm events Past Med Hx - medications (NSAIDs, Steroids, anticoagulants, platelets Alcohol use Previous bleeds Liver disease status Viral status
Examine for chronic liver disease, assess abdomen, consider PR
Ix - LFTs, CT/US, old endoscopy
Treatment of clotting in cirrhosis
DONT - they guide synthetic function
Unless doing a procedures
FFP if INR>1.5
Platelets if <50
Massive haemorrage protocol if relevant
Pharmacological tx of upper GI bleed
TERLIPRESSIN
PPI - omeprazole, Hong Kong
TXA
Broad Abx - ceftriaxone
?erythromicin for emptying
Thiamine/multivits (stop encephalopathy)
Lactulose
How does Terlipressin work
Side effects:
Pro-drug of vasopressin
Acts on V1 receptors
Causes sphlanic vasoconstriction —> reduced portal flow and pressure
Lowers variceal pressure
Side effects - increase SVR, reduced CO, reduced CBF
Tx of massive upper GI
Call for help - gastro, ICU, anaesthetist, haem
Activate Massive Haemorrhage Protocol
ABCDE, allow permissive hypotension
Resus with blood products
Secure airway, RSI, cricoid, monitor. PPE for bloodsplashes
Theatre, endoscopy
Sengstaken Blakemore
Features of SBT
Two balloons, oesophageal and gastric
3 ports - balloons x2 and one for gastric suction
4 in Minnesota - 2 suction ports
Set up a Sengstaken tube
Test inflate both balloons with 50mls air (could use a manometer)
Lube
Insert into the mouth to 50cm at level of teeth
Insert 20mls air, listen over stomach, insert 50mls. CXR to confirm
Fully deploy - 50ml blouses of air up to 250mls
Traction on a 500ml fluid bag
Note depth.
Assess bleeding via SBT
Apply suction to gastric lumen and empty stomach
Lovage with 50mls and aspirate
If oesophageal - inflate to pressure of 40mmHg (sphygmomanometer)
Oesophageal need to come down for 5 minutes per hour
Complications of SB tube
Aspiration
Hernia thing balloon
Perforation- gastric balloon in oesophagus
Muscosal ischaemia - excess pressure or inflated a long time
