Gastroenterology: Hepatopancreatobiliary system

Question 1

A 15 year old girl presents to A+E with as she was hard to rouse. She appears slightly yellow, her wrists jerk when flexed and she has hepatomegaly on abdominal palpation. She was found in her bathroom with a box of paracetamol next to her.

Answer 1

Acute liver failure

Reduced liver function causes

jaundice (lack of bilirubin conjugation)

Flapping tremor, confusion and drowsiness (reduced urea breakdown –> ammonia accumulation –> hepatic encephalopathy)

Hepato/splenomegaly (inflammation)

Question 2

What are the main lab tests that suggest liver failure?

Answer 2

Low albumin and PT (redued synthetic function)

Deranged AST, ALT, ALP (damage to liver)

Question 3

How do you treat acute liver failure?

Answer 3

Vitamin K (increase PT)

Lactulose 10-20mg/8 hrs (reduce ammonia)

Antibiotics eg cefotaxime (prophylaxis against SBP)

Stop hepatotoxic drugs

Monitor cardiovascular status and glucose

Question 4

What do you avoid giving to a liver failure patient with ascites?

Answer 4

Sodium

Reducing bodily sodium improves fluid excretion

Question 5

How does chronic decompensated liver failure present?

Answer 5

Similar to acute but also:

Spider angioma, palmar erythema, gynaecomastia (impaired estrogen secretion)

Caput medusae, ascites (portal hypertension)

Question 6

What investigation findings point towards decompensated chronic liver failure?

Answer 6

Low albumin, raised PT (impaired synthetic functions)

USS: Nodular ‘corkscrew’ appearance, enlarged portal vein

some centres can do ELF, >7.7 in fibrosis

Question 7

What does this triad of features suggest:

1. Cirrhosis
2. Ascites
3. Renal failure

Answer 7

Hepato-renal syndrome

Portal hypertension leads to stretching of the vessels, resulting in blood pooling there

Resultant ischaemia of the kidneys impairs function

Question 8

What dietary advice should be given to those with liver cirrhosis?

Answer 8

High calorie and protein (impaied glycogen for energy storage)

Low sodium (prevent hypertension, ascites)

Every 2-3 hours (less able to breakdown nutrients)

Question 9

What are the complications of decompensated chronic liver cirrhosis?

Answer 9

Malnutrition

Varices

Ascites

Spontaneous bacterial peritonitis

Encephalopathy

Renal failure

Question 10

How do you deal with a spontaneous bacterial peritonitis?

Answer 10

Ascitic culture and then direct antibiotics (cephalosporin)

Question 11

How do you deal with hepatic encephalopathy?

Answer 11

Lactulose 10-20mg/8 hours

Reduces ammonia in body

Question 12

How do you manage ascites in liver cirrhosis?

Answer 12

Perform ascitic tap (to diagnose)

Low salt diet (to reduce retention)

Spironolactone +/- furosemide (to excrete excess)

Question 13

How can you manage the two types of hepatorenal syndrome?

Answer 13

Rapid progression: terlipressin and dialysis

Slow progression: hepatic portal stenting

Question 14

What is the criteria for paracetamol induced liver failure?

Answer 14

Arterial pH < 7.3 after 24 hours

OR

All 3 of:

• PT >100s
• Creatinine >300umol/L
• Grade III/IV encephalopathy

Question 15

What are the 3 most common causes of chronic liver failure

Answer 15

Alcoholic liver disase

Non-Alcoholic Fatty Liver Disease

Hepatitis: B and C

Question 16

What 3 drugs should you ask about in someone with acute liver failure?

Answer 16

Paracetamol

Cocaine

Mushrooms

Question 17

What viruses commonly cause acute liver failure?

Answer 17

Hepatitis A and B

Question 18

How do you manage varices when:

a) actively bleeding
b) stable

Answer 18

a) Terlipressin, vit K, FFP, broad spec antibiotics and endoscopic repair
b) Propanolol, band ligation/sclerotherapy, TIPS