Liver, Biliary Tree And Pancreas Flashcards
How do you manage acute alcohol poisoning?
Keep them awake
Keep them sat up
Give water if tolerated
If unconscious but breathing, put them in the recovery position
Keep them warm
Stay with them
How do you treat paracetamol overdose?
N-acetylcysteine or liver transplant.
Which hepatitis viruses can be immunised against?
Hepatitis A
Hepatitis B
What is the first line symptomatic treatment for delirium tremens?
Oral lorazepam
Or: parenteral lorazepam or haloperidol
What is the first line treatment for alcohol withdrawal syndrome?
Benzodiazepine or carbamazepine
Oral Chlordiazepoxide 10-50mg/6hrs for three days
Possible adjunct: benzodiazepine or carbamazepine.
May require vitamins if chronic alcoholic.
Who should be admitted and offered medically assisted alcohol withdrawal?
- People with alcohol withdrawal seizures (AWS)
- Those at high risk of AWS or delirium tremens
- Those under 16
- Those with learning disabilities
What is first line treatment for alcohol withdrawal seizures?
Quick acting benzodiazepine (lorazepam)
What is the first line treatment for suspected wernicke’s encephalopathy or for prophylaxis of this?
High dose thiamine
In the treatment of decompensated alcoholic liver disease, what are the two requirements for transplant?
- Three months abstinence
2. Three months best management hasn’t compensated the condition
What are the five steps that NICE recommends for the treatment of alcoholic liver disease?
(2 steps are dependant on comorbidities)
- Assess for liver transplant
- Treat active infections and GI bleeds
- Control any renal impairment
- Discuss and offer corticosteroids (Reduces inflammation in the liver)
- Offer nutritional support - consider nasogastric tube
How do we treat pancreatitis?
Symptomatic and curative
(Same for acute and chronic)
- Treat root cause if possible:
- Cholecystectomy or ERCP (If gallstone, large duct obstructive pancreatitis)
- Stop alcohol intake
- Offer coeliac axis block, splanchnicectomy (control pain in small duct obstructive pancreatitis) - IV fluids
- Nutritional support: enteral feeding (NG)
- Morphine or fentanyl
- Offer enzyme supplements if signs of exocrine insufficiency are due to chronic pancreatitis
- Offer benzodiazepines if cause is alcohol
A patient has just been diagnosed with diabetes type 2:
Which investigations do you want to do?
- Serum lipids (indicates risk factors for CVD)
- Serum creatinine (check kidney function for microvascular issues)
- Retinopathy (check for retinal damage)
What is the treatment pathway for diabetic ketoacidosis and hyperosmolar hyperglycaemic state?
- If BP<90mmhg 500ml 0.9% saline over 15 mins: (prevent cerebral oedema)
- If unconscious use airway protection
- Give potassium chloride solution (avoid arrhythmias)
- Give IV insulin infusion
- Continue any established insulin regimes: should give long acting insulin - might die if hyperglycaemic for too long
- LMWH (VTE prophylaxis)
- Monitor serum potassium, ketones and sugars
What is the treatment for severe hypoglycaemia?
- Glucose 10-20g PO and repeated after 15 minutes. (2 teaspoons of sugar)
- IV glucagon: if unconscious - works by releasing the stores of glycogen in the liver
Glucagon will not work in a patient with cirrhosis
What kind of things should be covered in a management care plan for diabetes type 1?
Condition education Nutrition education Insulin regime dose adjustment Self-monitoring Hypoglycemia management Pregnancy in diabetes advice Monitoring for complications CV risk information
What is the long term management of type one diabetes?
- Offer multiple daily injection basal–bolus insulin regimen:
A) Basal insulin: long-acting (To avoid hypos in between mealtimes)
- Levemir
B) PRN insulin:Short-acting (for meal time increases)
- Aspart
- Correction dosing (How much insulin to use for target glucose level)
- Carbohydrate counting and hyperglycaemic effects of certain foods
- Sick day rules for T1DM (insulin requirements change when comorbidly ill)
- Adjustment for sport/stress
- Annual DM check - what’s the point in sorting it initially but you don’t check to see it’s working?
- Attend DAFNE programme within 2 years of diagnosis
(Diabetes Adjustment For Normal Eating) - Warning patient: avoiding unplanned pregnancies is an essential component of diabetes education
What are the requirements to move from manual insulin injection to continuous subcutaneous injection?
Multiple daily injections lead to disabling Hypoglycemia (repeated, unpredictable, causing significant adverse effect on QOL)
Or:
HbA1C remain high despite care
How do you manage a patient with type 1 diabetes who is thinking of becoming pregnant?
(Kinda like a yearly review, we want to know what of state they are in relative to their DM, are they fit for pregnancy?)
Need to control glucose and ketone level before becoming pregnant.
Review glucose targets
Review medications (both for the DM and for any complications they have)
Inform them of risks
Reassess for nephropathy and retinopathy
For a patient with type one diabetes: she has become pregnant and we need to check/adjust her medications, what do we do?
- Change insulin to Isophane
- Discontinue ACE-I
- Assess for continuous subcutaneous insulin infusion (glucose can be harder to control by normal injection during pregnancy)
When should a baby be born to a patient with type 1/2 diabetes?
- how many weeks? Late? Early?
37-38 weeks, slightly late.
If there are any complications: before 37 weeks.
What are the 3 principles of diabetes adjustment for normal eating (DAFNE)?
- Carbohydrate estimation (the ‘carbohydrate portion’ - 10g)
- Insulin dose adjustment (basal/bonus regime)
- Managing hypos and other topics
What is the management pathway for diabetes type two?
Think: condition control, risk reduction, complication control
- Lifestyle modification:
- 150 minutes exercise p/week
- Reduced portion size - Metformin 500mg PO once daily
- Simvastatin 20-40mg PO once daily
- (prevent macrovascular risk) - BG self-monitoring and HbA1C testing every 6 months, target is 6.5% HbA1C
- If patient has nephropathy: Lisinopril 2.5-5mg PO once daily
- Retinoscopy, kidney function tests, serum lipids, BMI
- Referral to structured education programme
- Xpert
- DESMOND - Annual checks every 3-6 months:
- Lipids
- U and E’s: creatinine for egfr and for creatinine:albumin ratio
- Foot exam
- Eye screening
If you’re presented with a patient with newly diagnosed diabetes, what tests other than blood glucose do you want to do?
- Serum lipids - CVD risk
- U’s and E’s - kidney function, signs of nephropathy
- BP measure- kidney function and risk factor to kidney and heart
- Neurological test - any autonomic neuropathy
- BMI - independent risk factor
- Retinoscopy - any signs of retinopathy (first to manifest)
What options do we have for treating nephropathy complications of diabetes?
Diet - low protein diet
Calcium supplements - loss of calcitriol
Vitamin D - loss of calcitriol
Bicarbonate supplements - metabolic acidosis
EPO injections - loss of erythropoiesis drive
Dialysis - ESRF
What is the management pathway for hepatitis B?
- Test: hepatitis B antigen/antibody status, HIV, LFTS, FBC and prothrombin time
- Vaccinate for hepatitis A
- Offer hepatitis B vaccine to contacts
- Notify health protection unit
- MANY DRUGS SHOULD BE AVOIDED OR KEPT TO LOW DOSE IF HEPATIC METABOLISM IS IMPAIRED-
5. symptomatic pain relief: paracetamol or ibuprofen (not strong opioid if liver function is impaired)
6. Symptomatic nausea relief: 5 days metoclopramide or cyclazine
7. Symptomatic itch relief: Chlorphenamine
8. Monitor hepatitis serology every 6 months - TREATMENT; clear surface antigen, prevent immune attack on liver-
9. 48 Weeks PEG interferon alfa or Nucleoside analogue (tenofovir/entecavir)
What is the treatment for hepatitis C?
- PEG interferon Alfa with ribavirin
- OR: Sofosbuvir or ledipasvir
- In end stage liver failure: liver transplant
- by cure, we mean cause complete absence of detectable virus in the blood, genotype 1 has lowest cure rate (56%) and require longer treatment
What is the treatment pathway for haemochromatosis?
- Observation and 3 yearly checkup (If stage 0: asymptomatic and normal transferrin sat)
- Lifestyle changes; avoid iron and iron-containing supplements, avoid vitamin C (increases iron uptake) and avoid alcohol
- Hep A and B vaccination
- Phlebotomy (If stage 2-4)
