Gastro - OSCE - Liver

Question 1

How do you do an ascitic tap

Answer 1

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

Question 2

Tests to do with ascites

Answer 2

Cell count and differential
MC&C
LDH
Albumin
Amylose
Glucose
Cytology

Question 3

SBP diagnosis on ascites

Answer 3

Polymorphonuclear cells (PMN) >250 PMN/mm3

Question 4

How would TB look in ascites

Answer 4

Large lymphocyte count instead of PMN

Question 5

Once SBP has been diagnosed, what other Ix might you do

Answer 5

Renal biochemistry

Abdo ultrasound

Question 6

Causes of an AKI in liver disease

Answer 6

Pre-renal - hypoperfusion, sepsis, cardiac and hepatic failure

Renal - nephrotoxic drugs, intirinsic disease

Post - renal obstruction

HRS

Question 7

Mortality of type 1 HRS

Answer 7

90%

Question 8

What features suggest synthetic failure

Answer 8

Low albumin

Raised INR

Question 9

Management of refractory ascites

Answer 9

Sodium restriction
High dose furosemide and spironolactone
Beta blockers for portal hypertension
TIPS
Liver transplant

Question 10

Triad of acute liver failure

Answer 10

Jaundice

Encephalopathy

Coagulapathy

Question 11

Classifcation of acute liver failure

Answer 11

O Grady - Interval from jaundice to encephalopathy:

Hyper acute - less than 7 days

Acute 1 to 4 weeks

Sub acute 4 weeks 6 months

Question 12

Differentials of acute liver failure

Answer 12

Drug induced - paracetamol
Viral Hep ABC,E

Alcoholic Hep
Auto immune hep

Miscellaneous- ischaemic hep, Budd Chiari, HELLP, fatty liver, Wilsons

Question 13

Budd chiari presentation

Answer 13

Abdo pain
Ascites
Liver enlargement

Due to hepatic venous obstruction

Question 14

Investigations of acute liver failure

Answer 14

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

Question 15

Treatment of paracetamol overdose

Answer 15

ABCDE
Establish time of ingestion
Start NAC if level is above treatment line

Correct hypoglycaemia - dextrose

Question 16

Grading of encephalopathy

Answer 16

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

Question 17

Managing cerebral oedema in encephalopathy

Answer 17

Head up tilt
Loose ties
Normocapnoea
Maintain CPP 90
ICP monitor
Normoglycaemia
?refer

Question 18

Causes of Upper GI bleed

Answer 18

Peptic ulcer (gastro/duodenal)

Oesophagitis, gastritis, duodenitis

Varices

Mallory Weiss

Angiodysplasia

Aorta-enteric fistula

Malignancy (oesophagus/gastric)

Question 19

History and examination in cirrhosis plus Upper GI bleed

Answer 19

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

Question 20

Treatment of clotting in cirrhosis

Answer 20

DONT - they guide synthetic function

Unless doing a procedures

FFP if INR>1.5
Platelets if <50

Massive haemorrage protocol if relevant

Question 21

Pharmacological tx of upper GI bleed

Answer 21

TERLIPRESSIN
PPI - omeprazole, Hong Kong
TXA

Broad Abx - ceftriaxone
?erythromicin for emptying

Thiamine/multivits (stop encephalopathy)

Lactulose

Question 22

How does Terlipressin work

Side effects:

Answer 22

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

Question 23

Tx of massive upper GI

Answer 23

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

Question 24

Features of SBT

Answer 24

Two balloons, oesophageal and gastric

3 ports - balloons x2 and one for gastric suction

4 in Minnesota - 2 suction ports

Question 25

Set up a Sengstaken tube

Answer 25

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.

Question 26

Assess bleeding via SBT

Answer 26

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

Question 27

Complications of SB tube

Answer 27

Aspiration
Hernia thing balloon

Perforation- gastric balloon in oesophagus

Muscosal ischaemia - excess pressure or inflated a long time