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Pete FFICM SOE/OSCE > Gastro - Viva - Chronic Liver Disease > Flashcards

Gastro - Viva - Chronic Liver Disease Flashcards

1
Q

Causes of chronic liver disease

A

Alcohol

Infective - Hep B and C

Drugs - Methotrextate, Methyldopa, Amiodarone

Cholestasis - Primary biliary cirrhosis, sclerosing cholangitis

Autoimmune hepatitis

Hereditary - Wilson, Haemachromatosis, a1 deficiency

Vascular - Budd -Chiari, veno- occlusive disease

Non Alcoholic Fatty Liver Disease NAFLD

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2
Q

Scoring systems in the prognostication of CLD

A

Child-Pugh Score

Model of End Stage Liver Disease (MELD)

SOFA can be used to discriminate survivors from non

UK Model for End Stage Liver Disease (UKELD) to aid selection of transplant candidate

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3
Q

Waht is the Child Pugh Score

A

Scored 1-3, 5 catergories

Encephalopathy –> None, Grade 1-2, Grade 3-4
Ascites None, Mild, severe (refractory)
Bilirubin <34, 34-50, >50
Albumin >35, 28-35, less than 28
INR <1.7, 1.7.- 23, >2.3

Grade A 5-6 points
B 7-9
C 10-15

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4
Q

Survival based on child pugh grades

A

A (5-6) 100% at 1 year, 85% at 2
B (7-9) 81% at 1, 57% at 2
C (10-15), 45% at 1, 35% at 2

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5
Q

MELD score

A

Predicts mortality in hospitalised patients with cirrhosis

MELD, taken from bilirubin, INR, creatinine

MELD = (3.78 x ln{bili])+(11.2x ln [INR}) + 9.57 (ln creatinine) + 6.43

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6
Q

Why do cirrhotic patients come to ICU

A 
Management of bleeding varices
Management of coagulopathy
Alchoholic hepatitis
AKI
Severe sepsis
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7
Q

What is portal hypertension

A

Portal pressure > 10mmHg and is associated with :

porto-systemic collateral venous circulation
ascites
splenomegaly

Clinical diagnosis as portal pressure can only be diagnoised directly via a TIPSS

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8
Q

Main complication of portal hypertension

A

Varices leading to massive upper GI bleed

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9
Q

Treatment of variceal bleed

A

ABCDE treat as found

Specific:
Volume - transfuse blood and blood products
Vasoconstrictors - terlipressin (or?somatostatin)
Endoscopy within 24 hours using variceal band ligation

Prevent complication - antibiotics

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10
Q

and if you cants control bleed via OGD

A

Balloon tampanade via Sengstaken blakemore

Further endocscopy

TIPPS
Surgery

Consider TIPPS or transplant to prevent rebleeds

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11
Q

What is a TIPPS

A

Transjugular Intrahepatic Portosystemic Stent Shunt

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12
Q

What does a TIPPS do

A

Endovacular procedure

Makes a communication between the inflow portal vein and the outflow hepatic vein, using a stent.

Reduces portal pressure in patients with complications related to portal hypertension (bleeding, dieuretic resistant ascites)

Divert blood from hepatic vein, to reduce pressure gradient between portal and systemic circulations.

Also useful in encephalopathy to divert blood from liver

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13
Q

What is HepatoRenal Syndrome

A

Type of renal failure in patients with cirrhosis or fulminant liver failure.

It is a PRE-RENAL AKI that does not respond to fluids

Abnormal autoregulation with renal vasoconstircion due to sympathetic stimulation and dilation of splanchnic vessels.

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14
Q

What is the characteristic feature

A

Low fractional excretion of sodium with progressive rise in plasma creatinine in patient with CLD

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15
Q

Diagnostic criteria of HRS

A

Cirrhosis with ascites
Creatinie above 133
No improvement in creatinine after 2 days of dieurteitc withdrawel and volume expansion with albumin

No shock
No nephrotoxins
No renal parenchnymal disease

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16
Q

Types of HRS

A

2

Type 1- Rapidly progressive decline in kidney function with mortality > 50%

Type 2- More indolent course with dieuretic resistant ascites

17
Q

Tx options for HRS

A

Trial of terlipressin and plasma expansion with albumin

TIPPS may improve renal function

Definative - tranplant

18
Q

What is SBP

A

Ascitiv fluid infection without an evident intra-abdominal surgically treatable source

Almost always occurs in paitents with cirrhosis and ascites

19
Q

Presenting features of SBP

A

non specific

Fever, hypotension, abdo pain, altered mental status

20
Q

Fluid wcc?

A

Neutrophil greater than 250 cells/mm3 and / or positive periotoneal fluid cultures

21
Q

Treatment of SBP

A

Empriic abx and local sensitivitys

Smal study shower terlipressin improved haemodynamics

22
Q

Features of hepato-pulmonary syndrome

A

Poorly understood, with intrapulmonary shunting and hypoxia in patients with cirrhosis

Dyspnoea, hypoxia that are worse upright (platypnoea and orthodeoxia)

Poor prognosis

Indication for orthotopic liver transplant

23
Q

What is alcholic hep

A

Syndrome of progressive inflammatory liver injury with long term alcohol use.

Severe alcoholic hep –> mortality of 50% in 30 days

24
Q

How to diagnose alco hep

A 
Hx of alcohol intake
Fever
worsening LFTs (inc raised bili and aminotransferases)

May not have cirrhosis

25
Q

Tx of alco hep

A

Supportive
Steroid in severe cases –> reduce inflammation

Transfer to tertiary centre in severe cases

Pentoxyphyline reduces incidence of HRS in alco hep.

Abstinance in long term

26
Q

Define chronic liver failure

A

Deterioration in hepatic synthetic and metabolic function of grater the 26 weeks duration

WITHOUT ENCEPHALOPATHY

27
Q

Define acute on chronic liver failure

A

chronic liver disease who develops acute deterioration in liver function and organ dysfunction

28
Q

Systemic manifestations of CLD

A

CVS - CAD, Cardiomyopathy, Cardiac Failure

Resp - Pulmonary Hypertension, fibrosis, VQ mismatch

Neuro - polyneuropathy, autonomic dysfunction, encepph

Endocrine _ DM, Thyroid Disease, hyper lipid

Haem - anaemia, hypersplenism, neutropenia, thrombocytopenia, coagulapathy

GI - portal gastropathy, varices,
Panc and biliary Ca

Renal - glomerularnephritis from hep virus nephropathy
HRS

Skin - pruritis, palmar erythema, spider naevia, porphyria curtanea tarda

29
Q

Grading of encephalopathy

A

West Haven

1 - behaviour change without change in conciousness
2- drowsiness, disorintated
3 - Rousable to voice, confused, incoherent
4 - Coma, decorticate posturing

30
Q

Scoring systems

A

MELD

Child Pugh

31
Q

Features of Child Pugh

A 
Bilrubin
Albumin
Ascites
INR
Enceph
32
Q

Grades of Child pugh

A

A - 5-6
B - 7-9
C 10-15

33
Q

Life expectancy by childs score

A

A - 15-20 years
B - 4 - 15 years
C - 1-2 years

Peri op motality rises ( 10%, 30%, 80% for laporotomy)

34
Q

Meld features

A

INR plus bilirubin plus albumin

BUT
Add sodium if MELD > 12

35
Q

MELD score points

A

> 9 refers to transplant centre

> 24 consider for transplant

36
Q

What causes acute on chronic failure

A

Infection (bacterial, viral, funalg)
Alcolic hep
Trauma (surgery)

In 40%, no cause found

37
Q

Predictors of mortality in acute on chronic

A

Age,
WCC
Degree of organ dysfunction

38
Q

Critical care manamagent of acute on chronic

A

Supportive
ABCDE
Find the precipitating cause
Restore the circulating volume, maintain organ perfusion wiht vasoactives

?cardiac output monitor

Early Abx
Invasive fungaemia is rare –> fungal colonisers are not

Albumin

Adrenocortical failure is common but steroids do not improve mortality

HF to remove ammonia

Liver transplant - HOWEVER, no provision for emergency transplant in chronic failures

Pete FFICM SOE/OSCE (199 decks)

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