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CP3 Management > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

1
Q

Tx of autoimmune hepatitis

A

Prednisolone 30mg OD

+azathioprine 1mg/kg/day following TPMT assays (reduced levels of TMPT expression lead to myelosuppression with azathioprine)

Taper prednisolone with a fall in LFTs

Aim to get to 10mg/day over 4 weeks

Long term therapy with low dose prednisolone (5-10mg) and azathioprine is then recommended

As with any steroid regime, bone/gastric protection required and monitoring should be performed

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2
Q

Tx Acute and chronic hepatitis B infection

A

Acute episode treated with supportive therapy and alcohol avoidance

95% recover and develop immunity

First line management of chronic hepatitis B is subcutaneous peginteferon-alpha-2a for 48 weeks

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3
Q

indications for liver biopsy in hepatitis

A

Chronic hepatitis

Cirrhosis

Suspected neoplastic disease

Storage diseases

Unexplained hepatomegaly

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4
Q

contraindications for liver biopsy in hepatitis

A

Prolonged PT

Platelet count <80

Ascites

Extra-hepatic cholestasis

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5
Q

Tx of pyogenic liver abscess

A

Aspiration under USS guidance

IVABx

Treating underlying cause

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6
Q

Tx amoebic liver abscess

A

Metronidazole for 5 days for the amoebic dysentry

USS drainage of abscess

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7
Q

Tx of hyatid cyst

A

Albendazole

FNA under USS guidance

Deworming of pet dogs

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8
Q

Tx of HCC

A

Surgery for solitary HCCs <3cm, however this carries a high risk of recurrence

Transplant if there are small tumours from cirrhosis as Resection in cirrhosis can lead to decompensation

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9
Q

Management of acute first presentation of ascites

A 
FBC (infection markers)
U+E (kidney function)
urine dip (nephrotic syndrome) 
LFTs
ascitic tap (for transudative/exudative) 
non invasive liver screen 
USS + duplex if possible, or CT

if hepatic origin: Tx of underlying disorder
sodium restriction
diuretics (spironlactone)
therapeutic paracentesis
prophylactic ciprofloxacin/co-trimoxazole for SBP prevention

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10
Q

Tx for hepatic encephalopathy

A

lactulose/mannitol

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11
Q

Tx of oesphageal varicie rupture

A

A-E resus
Terlipressin (if no CIs - PVD, recent MI, recent stroke etc)
prophylactic Abx
referral to gastro reg on call for endoscopic banding

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12
Q

prognosis of HCC

A

<6 months

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13
Q

Tx of cholangiocarcinoma

A

If they present early with jaundice, and can be cured with extended liver resection

Often however they present late in which case palliation may be achieved by stenting via ERCP

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14
Q

when should benign liver tumours be treated

A

if >5cm or symptomatic

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15
Q

how do you interpret an ascitic tap

A

Raised serum ascites albumin gradient (SAAG) = transudative ascites, associated with cardiac failure, cirrhosis of the liver

decreased SAAG = exudative ascites associated with nephrotic syndrome or, malignancy, pancreatitis and infection - especially TB

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16
Q

what are the 4 ways cirrhotic liver disease can decompensate

A

jaundice
encephalopathy
ascites
variceal haemorrhage

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17
Q

what are the only 4 things that cause ALT to go above 1000

A

autoimmune hepatitis
viral hepatitis
drug induced injury
acute ischaemic injury

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18
Q

what does ALT rarely climb above in alcoholic liver disease

A

400

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19
Q

when is GGT helpful in a liver screen

A

to establish if ALP is raised due to bone disease or liver disease, high ALP normal GGT = bone disease, whereas if both are raised it indicates liver pathology

20
Q

indications for splenectomy

A

Splenic trauma

Hypersplenism

Autoimmune haemolysis

21
Q

complication of splenectomy

A

Increased risk of infection – particularly from encapsulated organisms (strep. Pneumoniae) as the spleen usually contains a large amount of macrophages that phagocytose such bacteria

22
Q

management of a post-splenectomy patient

A

Mobilise soon after operation due to transient increase in platelets so LMWH in hospital, with aspirin advised in the short term

Immunise according to local protocol  
Pneumococcal 2 weeks prior to surgery or ASAP following emergency surgery  
HIB 
Men C 
Annual flu

Lifelong Penecillin V (erythromycin if allergic)
Does not protect against Hib

Advise to carry alert cards and seek immediate medical advice if there are any signs of infection, and urgent hospital admission if there is

If travelling abroad warn of severe malaria risks

This advice also applies to hyposplenic patients

23
Q

what abnormality on blood film indicates the patient has had a splenectomy

A

Howell-Jolly bodies

24
Q

what abnormality on blood film indicates splenectomy

A

howell-Jolly bodies

25
Q

Tx of wilsons disease

A

Chelating agents:

D-Penecillamine
Trientene

26
Q

Tx haemachromatosis

A

Venesection

1 unit per week initially

27
Q

what is mirizzi syndrome

A

gallstone impacted in the cystic duct/hartmans pouch causing extrinsic compression of the common hepatic duct

28
Q

what is bouveret syndrome

A

gallstone impating into duodenum causing gastric outlet obstruction

29
Q

Tx incidental gallstones

A

Cholecystectomy only indicated if the patient is at significant risk of complications due to co-morbidities (diabetes/renal failure)

Young patients may fit this criteria as there is a long time for symptoms to develop

30
Q

Tx biliary colic due to gallstones

A

Admit for analgesia, bed rest and fluids – keep NBM

Elective laporoscopic cholecystectomy
Preferably during first 72 hours (hot cholecystectomy)
Otherwise scheduled for 6 weeks later (cold)

T tubes are often used to drain the common bile duct after surgery and residual stones can be removed via the tube

Medical treatments involve giving bile salts orally (chenodeoxycholic acid) for small, non-calcified stones in the minority of patients unfit for surgery

31
Q

Tx cholecystitis

A

Admit for analgesia, bed rest and fluids – keep NBM

IV cefuroxime

Elective laporoscopic cholecystectomy
Preferably during first 72 hours (hot cholecystectomy)
Otherwise scheduled for 6 weeks later (cold)

T tubes are often used to drain the common bile duct after surgery and residual stones can be removed via the tube

Medical treatments involve giving bile salts orally (chenodeoxycholic acid) for small, non-calcified stones in the minority of patients unfit for surgery

32
Q

what organism commonly causes SBP

A

e-coli

33
Q

Tx of chronic cholecystitis

A

Laporoscopic cholecystectomy

+ cholangiogram to ensure no stones remain in the common bile duct (if so, removed with an ERCP)

34
Q

Tx of obstructive jaundice due to stones

A

ERCP for sphincterotomy and to remove the stones using a balloon or dormia basket, as an emergency if there is a high fever

Any intervention preceded with IV vit K, as lack of bile salts means this may not have been absorbed well

Elective laporoscopy cholecystectomy

35
Q

Tx of ascending cholangitis

A

Sepsis 6 bundle with IV cefuroxime + metronidazole + emergency ERCP

36
Q

Tx of gall bladder carcinoma

A

Surgical

Radical cholecystectomy +/- liver resection if caught incidentally

However most tumours present too late for surgical intervention (survival is short)

37
Q

what is the definitve treatment for variceal disease in chronic liver failure

A

TIPS (transjugular intrahepatic portosystemic shunt) procedure

38
Q

Tx of pruitis

A

Cholestyramine

39
Q

Tx of alcohol withdrawals

A

Chlordiazeperoxide (benzo) tapered down over 7 days + pabrinex IV (contains the vitamins thiamine, riboflavin, pyridoxine, ascorbic acid and nicotinamide) - oral thiamine required for 28 days

40
Q

Tx of acute pancreatitis

A

A-E resus

Aggressive fluid resus (500ml bolus then reassess, may go up to 2L)

Catheterisation

Hourly pulse, BP, urine output+ daily bloods (FBC, Ca2+, U+Es, glucose, ABG)

Anlgesia (opiates)

NBM until pain free (rests the pancreas)

NG tube suction If ileus/emesis

PPI to prevent stress ulcer

Anticoagulation (if in bed all day)

Consider ITU - Apache II etc

Antibiotics In serious cases

Laporotomy and debridement if there is abscess or necrosis on CT

Urgent ERCP (if due to gallstones)

Find and treat causative agent

41
Q

late complications of acute pancreatitis

A

Pancreatic pseudocyst

Abscesses

Bleeding from elastase eroding a major vessel thrombosis of the splenic/gastroduodenal arteries causing bowel necrosis

Fistulae

42
Q

what 2 scores are important for upper GI bleed and what are their main component

A

Glasgow-blatchford - SBP, Urea, Hb

Rockall score post endoscopy

43
Q

interpretation of Glasgow-blatchford score

A

score >6 = high likelihood for intervention

score >0 = likely to require intervention

44
Q

pancreatitis scoring systems and interpretations

A

APACHE 2 (>9 = severe mortality)

Modified Glasgow criteria (>3= ITU

Ranson criteria

45
Q

Tx pancreatic pseudocyst

A

Majority of pseudocysts only require supportive care and regular monitoring

Indications for drainage  
Complications  
Bleeding  
Infection 
Relief of symptoms

Concerns about malignancy
Cytology
Cystic fluid analysis

Drainage (if done) can be done via ERCP, laporoscopy or percutaneous

46
Q

Tx pancreatic neoplasm

A

Patients discussed at MDT

10-15% of patients are suitable for a surgical procedure (Whipple)
Curative procedure
Tumour must be <3cm with no Mets in a fit patient
Post-op chemo has been shown to increase survival

Non-curative surgery provides no survival benefit

If the tumour is not operable ERCP/stent insertion may help jaundice/anorexia

Careful management of the endocrine and exocrine derangements

47
Q

prognosis of pancreatic neoplasm

A

Mean survival <6 months

5 year survival <2% rising to 5-15% following whipples procedure

Ampullary and islet cell tumours carry a better prognosis as they often present relatively early

CP3 Management (11 decks)

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