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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
Tx of wilsons disease
Chelating agents: D-Penecillamine Trientene
26
Tx haemachromatosis
Venesection 1 unit per week initially
27
what is mirizzi syndrome
gallstone impacted in the cystic duct/hartmans pouch causing extrinsic compression of the common hepatic duct
28
what is bouveret syndrome
gallstone impating into duodenum causing gastric outlet obstruction
29
Tx incidental gallstones
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
Tx biliary colic due to gallstones
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
Tx cholecystitis
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
what organism commonly causes SBP
e-coli
33
Tx of chronic cholecystitis
Laporoscopic cholecystectomy + cholangiogram to ensure no stones remain in the common bile duct (if so, removed with an ERCP)
34
Tx of obstructive jaundice due to stones
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
Tx of ascending cholangitis
Sepsis 6 bundle with IV cefuroxime + metronidazole + emergency ERCP
36
Tx of gall bladder carcinoma
Surgical Radical cholecystectomy +/- liver resection if caught incidentally However most tumours present too late for surgical intervention (survival is short)
37
what is the definitve treatment for variceal disease in chronic liver failure
TIPS (transjugular intrahepatic portosystemic shunt) procedure
38
Tx of pruitis
Cholestyramine
39
Tx of alcohol withdrawals
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
Tx of acute pancreatitis
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
late complications of acute pancreatitis
Pancreatic pseudocyst Abscesses Bleeding from elastase eroding a major vessel thrombosis of the splenic/gastroduodenal arteries causing bowel necrosis Fistulae
42
what 2 scores are important for upper GI bleed and what are their main component
Glasgow-blatchford - SBP, Urea, Hb Rockall score post endoscopy
43
interpretation of Glasgow-blatchford score
score >6 = high likelihood for intervention score >0 = likely to require intervention
44
pancreatitis scoring systems and interpretations
APACHE 2 (>9 = severe mortality) Modified Glasgow criteria (>3= ITU Ranson criteria
45
Tx pancreatic pseudocyst
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
Tx pancreatic neoplasm
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
prognosis of pancreatic neoplasm
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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