Houseman handbook - GI

Question 1

Acute liver failure

Answer 1

Definition
 - INR >=1.5
 - Hepatic encephalopathy within 26/52 onset of symptoms
 >>> Hyperacute: <1/52
 >>> Acute >1-4/52
 >>> Subacute >4-26/52
 - No pre-existing liver disease

Classification

• Hyperacute: moderate Px, common cerebral edema, prolong PT, slight raise bili
• Acute: poor Px, common cerebral edema, prolong PT, raise bili
• Subacute: poor Px, infreq cerebral edema, slight prolong PT, raise bili

Etiology of acute liver failure
- DRUGS! (steroid, immunosupppressant, chemo, OTC, herbal, ectasy)
- Investigation
&raquo_space;> Bld x CBC clotting LRFT glc ABG lactate
Hep serology (ABDE) HBV DNA
Autoimmune markers (ANA ASMA anti-LKM1)
Metabolic marker (ceruloplasmin if <50yo)
Toxicology (paracetamol lvl)
Anti-HIV
HKPIC 27722211 for herbal formula review

Mx
ICU
1-1.5g protein/kg/day
Avoid panadol
NAC for both paracetamol/ non-paracetamol related ALF
>> Loading: 150mg/kg/H in D5 over 1hour
>> then 12.5mg/kg/H in D5 over 4hours
>> then 6.25mg/kg/H in D5 for 67hours
Nucleotide analogue if HBV+

Question 2

Complications of acute liver faiure

Answer 2

Hepatic encephalopathy

• Grade 1/2: CTB to exclude other causes, avoid stimulation, lactulose
• Grade 3/4: ET tube + mech ventilation, sedation (propofol), elevate head, BZD/ phenytoin if seizure, ICP monitoring

Intracranial hypertension

• Mannitol 0.5-1g/kg IV over 30-60mins, repeat q4H (max 2x), stop if Sosm >320/ vol overload, +RRT if renal failure
• Hyperventilation keep PaCO2 4-6kPa
• ICU: hyperteonic saline and barbituate, therapeutic hypothermia (32-34 degrees)

Infection
- Low threshold for antibacterial/ antifungal

Coagulopathy

• Variceal bleeding: think budd chiari, prophlactic famotidine/ PPI
• VitK1 10mg IV q24H
• Replace for thrombocytopenia (if <50-70 x 10^9 / INR >=1.5) if h’age/ before invasive procedure

HD/ renal faiure

• fluid replacement (Dextrose to maintain euglycemia) aim MAP >75
• vasopressor (NE/ Dopa)
• Pul artery catheterization if still HD unstable

Question 3

UGIB (CGV/ hemetemesis)

Answer 3

NPOEM
BP P IO monitoring
Risk stratification by Rockall
Bld transfusion if Hb <7
IVF
W/H anticoagulant/ antu PLT
ET tube if massive hemetemesis/ supected compromised airway
NGT if massive hemetemesis/ IO

IV nexium 80mg stat, then 40 mg daily if not early endocsocpy (<24H)
IV augmentin 1.2g q8H/ IV levofloxacin 500mg q24H (max 7 days) if cirrhotic
Early OG

EMERGENCY endocscopy

• HD shock
• Massive hemetemesis / blood NG aspirate
• Suspected variceal bleeding

NOT for endoscopy

• suspected perforation
• unstable cardiac/ pulmonary condition

Post-endocsocpy
- if active bleeding ulcer/ visible vessel/ adherent clot resistant to vigorous irrigation, IV PPI for 72 hours
(pantoprazole/ esomeprazole 80mg stat then 8mg/ hour)
- for aspirin, resume within 3-5/7 if hemostasis

Repeat endoscopy if recurrent lbleeding
Angiographic embolization as option

NO NEED transexamic exid