GI Conditions pt 2 Flashcards
What is the secondary prophylaxis for variceal bleeding?
Non-selective B-blockade
Rpt endoscopic banding ligation
Transjugular intrahepatic porto-systemic shunt for varices resistant to banding
Management of Acute variceal bleeding
Resusc + transfuse if anaemia Correct clotting abnormalities w/ - Vit K - FFP - Platelet transfusions IVI terlipressin and somatostatin analogues alternatives Endoscopic banding Minnesota tube if bleeding uncontrolled
Pathogenesis of oesophageal varices
Progressive liver fibrosis + regeneration of nodules = contractile elements in liver’s vascular bed
Portal HT
Splanchnic vasodilation
Increased CO
Salt and Water retention
Hyperdynamic circulation/increased portal flow
Formation of collaterals between portal and systemic systems
Gastro-oesophageal varices is >10mmHg
>12mmHg variceal bleeding
Death
Name 6 kinds of liver failure
Acute hep failure
Acute-on-chronic: decompensation of chr liver disease
Fulminant hep failure: massive necrosis of liver cells
- Hyperacute: encephalopathy within 7d of onset of jaundice
- Acute: 8-28d
- Subacute: 5-25w
Causes of Liver failure
Infections
Drugs
Toxins: mushroom, alcohol
Vascular: veno-occlusive disease, Budd-Chiari syndrome
Other: primary biliary cirrhosis, alpha-antitrypsin deficiency, Wilson’s disease, malignancy
Fatty liver of preg - HELLP syndrome (Haemolysis, elevated liver enzymes + low platelets
Signs of Liver failure
Jaundice Hepatic encephalopathy Fetor hepaticus Asterixis/flap Constructional apraxia (cannot copy a 5 pointed star)
Specific tests for Liver failure
Blood: Clotting, glucose, paracetamol level, hep, CMV, EBV serology Ferritin Alpha1- antritrypsin Caeruloplasmin Autoantibodies
Microbiology: blood culture, urine culture, ascites tap for MC+S, neutrophils
Radiology: Abdo US, Doppler flow studies of portal vein
Neurophysiology: EEG, evoked potentials
What do you have to beware of in the management of liver failure
Sepsis, hypogly
GI bleeds/varices
Encephalopathy
Management of liver failure
20 degree head-up tilt in ITU – protect with intubation + NG tube
Urinary and Central venous catheters to help assess fluid status
Monitor T, resp, pulse, BP, pupils, urine output, wt – FBC, U+E, LFT INR daily
10% glucose IV, blood glucose every 1-4h
Treat the cause
- Malnourished: thiamine + folate
- Seizures with lorazepam
- Haemofiltration / haemodialysis
- Avoid sedatics
- PPI against stress ulceration
How would you treat the complications to Liver failure
- Cerebral oedema
- Ascites
- Bleeding
- Blind Rx of infection
- Low blood glucose
- encephalopathy
- Mannitol
- Restrict fluid, low salt diet, wt daily, diuretics
- Ceftriaxone
- 50mL 50% glucose IV
- Avoid sedatives, lactulose
Name the Fourgrades of hepatic encephalopathy
I: altered mood behavior, sleep disturbance, dyspraxia, poor arithmetic, no liver flap
II: increased drowsiness, confusion, slurred speech +/- liver flap, personality change
III: incoherent, restless, liver flap, stupor but not coma
IV: coma
There are two types of Hepatorenal syndrome
I: rapid progressive deterioration
Rx: terlipressin
2: steady deteriorating -6mo
Rx: liver transplant
Hereditary haemochromatosis signs and symp
- Early
- Late
- Tiredness, athralgia, less erections
- Slate-grey skin pigmentation, Hepatomegaly, cirrhosis, Dilated cardiomyopathy, osteoporosis
Specific tests for haemochromatosis
LFT (inc) Serum ferritin (inc) Transferrin saturation >45% Glucose: ?DM HFE genotype Imaging: chondrocalcinosis, Liver MRI for Fe overload, ECG / ECHO for cardiomyopathy
Management for haemochromatosis
Venesect
Vitamin prep containing no irone
Diet: low-Fe diet may help, tea, coffee, red wine with meals
Monitor lft, glucose/diabetes, HbA1c (may be low due to venesection)
Screen: serum ferritin, genotype (C282Y), LFT
Indications for liver transplant in chronic liver disease
Advanced cirrhosis secondary to
- Hep b, c, autoimmune
- Alcoholic liver disease
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Alpha1 antitrypsin deficiency
- Wilson’s disease
- Hepatocellular ca
Contraindications for liver transplant
Extrahepatic malignancy Multiple tumours Severe cardioresp disease Systemic sepsis HIV infection Non-compliance with drug therapy
What is deficient in alpha-1antitrypsin A1AT deficiency
A1at affecting the lung (emphysema) and liver (cirrhosis and hepatocellular ca, HCC)
Erpinopathy: serine protease inhibitors which controls inflammatory cascades
Associated with HCC, asthma, pancreatitis, gallstones, Wegener’s
Specific tests for alpha-1antitrypsin
Serum alpha1-antitrypsin Genotyping Liver biopsy: periodic acid Schiff +ve, diastase-resistant globules Phenotyping CT: to measure lung density
Management for alpha-1 antitrypsin deficiency
Supportive for emphysema and liver disease
Quit smoking
Giving IV a1at from human plasma
Liver transplantation in decompensated cirrhosis
Signs of autoimmune hepatitis
Fever Malaise Urticarial rash Polyarthritis Pleurisy Pulmonary infiltration Glomerulonephritis Amenorrhoea
Specific Tests for autoimmune hep
Serum bilirubin (inc) AST (inc) ALT (inc) Alk phos (inc) Hypergammaglobulinaemia FBC: anaemia, WCC dec, platelets dec = hypersplenism Liver bipsy MRCP: exclude PSC
How do u classify autoimmune hepatitis
I: <40yo, ASMA +ve, ANA +ve, high IgG,
Good response to immunosuppress
II: European kids, progress to cirrhosis, LKM1 antibodies +ve, ASMA -ve, ANA-ve
III: ASMA -ve, ANA, -ve, high IgG, SLA or liver pancrease antigen
Management of autoimmune hep
Immunosuppressant therapy: Prednisolone 30mg/d x1mo – stop at 2y, Azathioprine for steroid sparing agent
Liver transplant: decompensated cirrhosis
What is associated with autoimmune hepatitis
Haplotype: HLA A1, B8, DR3 D: diabetes mellitus A: autoimmune haemolysis P: pernicious anaemia G: glomerulonephritis U: ulcerative colitis A: autoimmune thyroiditis P: Primary Sclerosing Cholangitis
Typical presentation for non-alcoholic fatty liver disease (NAFLD)
Alcohol
Middle aged
Obese
Male
Risk factors for non-alcoholic fatty liver disease (NAFLD)
Parenteral feeding
Jejuno-ileal bypass
Dm
Dyslipidaemia
Wilson’s disease
Drugs: ex: amiodarone, methotrexate, tetracycline
Follow up for non-alcoholic fatty liver disease (NAFLD)
LFT
Glucose
Signs of Wilson’s disease
Liver disease: hepatitis, cirrhosis, fulminant liver failure
CNS signs: tremor, dysarthria, dysphagia, dyskinesias, dystonias, purposeless stereotyped movements, dementia, parkinsonism, micrographia, ataxia/clumsiness
Mood: depression mania, labile emotions
Cognition: low memory and quick to anger, slow to solve problems
Kayser-Fleischer rings
Haemolysis, blue lunulae, arthritis, hypermobile joints, grey skin
Specific tests for Wilson’s disease
Urine: 24h copper secretion is high LFTs High Serum Copper Serum caeruloplasmin decreased Molecular genetic testing Slit lamp exam: KF rings Liver biopsy MRI: degeneration of basal ganglia
