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FFICM > Liver / GI > Flashcards

Liver / GI Flashcards

1
Q

Acute liver failure

A
  • no cirrhosis
  • liver injury
  • coagulopaty
  • encephalopathy
  • < 26 weeks (jaundice –> HE time)
  • hyper acute < 1 week
  • acute 1-4 weeks
  • subacute 4-12 weeks
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2
Q

Causes of ALF

A
  • paracetamol toxicity
  • Drug induced - abx, AED, recreational
  • viral hepatitis, A B E EBV CMV
  • ischaemic
  • pregnancy
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3
Q

Budd - chiari syndrome

A

hepatic vein obstruction - clot / tumour
abdo pain, hepatomegaly, gross ascites

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4
Q

Manifestations of ALF

A

Failure of
- gluconeogenesis - hypoglycaemia
- ammonia clearance - hyperammonaemia
- lactate clearance - lactic acidosis
- synthetic function - coagulopathy
Other featutes
- ARDS
- hypotension / low SVR / high CO
- Raised ICP, cerebral oedema
- AKI

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5
Q

Hepatic encephalopathy

A

ammonia not cleared by liver
crosses BBB
Ammonia + glutamate –> glutamine in brain
glutamine - apoptosis, mitochondrial dysfunction
cerebral oedema, raised ICP

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6
Q

Acute liver screen

A

Assessing disease severity
- PT / INR / coagulation screen
- LFTs, conjugated/unconjugated bilirubin, CK, LDH
- Assessment of renal function
- ABG, lactate, arterial ammonia
Assessing aetiology
- Urine toxicology screen
- serum paracetamol
- Viral screen
- HBsAg, Anti-HBC IgM
- Anti-HAV IgM
- Anti- HEV IgM
- Anti-HSV IgM
- Anti-VZV IgM
- CMV PCR
- HSV PCR
- EBV PCR
- Parvovirus PCR
- VZV PCR
- Autoimmune screen
- ANA, ASMA, anti-soluble liver antigen, ANCA, globulin profile
Lipase
Amyalse

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7
Q

Standard care ALF

A

Glucose infusion 10-20%
stress ulcer prophyalxis
restrist clotting factors unless bleeding
NAC
avoid sedatives, nephrotoxic and hepatotoxic drugs
HE –. Critical care
Intubate if Gr 3 HE
antibiotics if inflammatory, haemodynamic alteration or progressive HE
Normal Na, Mg, Pho, K

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8
Q

Critical care management of ALF

A

Specialist - aetiology, transplant, TIPSS (variceal bleed, refractory ascites
Supportive care
- Resp : HFNO > NIV. low PEEP (ICP vs ARDS)
- intubate for gr 3 HE
- fluid resuscitation, Norad first line
- nutrition
- CVVH (ammonia removal > 150)
- antimicrobials
- avoid toxins
- NAC
Prevention of encephalopaty
- thiamine, lactulose, rifaximin, RRT

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9
Q

Referral to specialist centre

A

Paracetamol / hyper acute
- pH < 7.3 / bicarb < 18
- INR > 3 day 2 or > 4 after
- oliguria / elevated creatinine
- hypoglycaemia
- altered consciousness
- lactate unresponsive to fluid
Non-paracetamol
- pH < 7.3
- INR > 1.8
- oliguria, renal failure, Na < 130
- encephalopathy, hypoglycaemia, acidosis
- Bili > 300
- Shrinking liver size

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10
Q

Poor prognosis in ALF-

A
  • more severe liver injury
  • extra hepatic organ failures
  • subacute presentations
    transplant should be considered in those fulfilling Kings College criteria
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11
Q

Kings College criteria

A

Paracetamol
- pH < 7.25 after resusictation or
- latate > 3 or
- All 3 of INR > 6.5, creat > 300, gr 3 HE
Non-paracetamol
- INR > 6.5 or
- 3 out of 5
- Indeterminate or drug induced aetiology
- age < 10 or > 40
- jaundice - HE > 7 days
- Bili > 300
- INR > 3.5

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12
Q

transplant contraindications

A

substance misuse, overwhelming sepsis, refractory shock, uncontrolled intracranial hypertension
Alcohol
- alcoholic hepatitis
- > 2 episodes in 2 year of non-adherence with medical care
- > 2 episode’s in 2 years of returning to drinking
- illicit drug use

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13
Q

Specific complications in ALF

A

Coagulpathy - vit K, use TEG, avoidance f clotting factors unless bleeding
Ascites - low sodium, diuresis, drain if SBP or resp compromise
- portopulmonary hypertension - pulmonary vasodilators (hepatopulmonary syndrome = hypoxaemia and SOB sure to pulmonary dilation and shunting)

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14
Q

Decompensated liver disease

A

acute decompensation of cirrhotic liver failure with 1 or more of:
- jaundice
- worsening ascites
- overt encephalopathy
- GI haemorrhage
- bacterial infections
- coagulopathy

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15
Q

Acute on chronic liver failure

A
  • pre-existing liver failure
  • decompensation
  • 1 or more organ failure (CLIF-SOFA) 1a –> 3
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16
Q

Portal hypertension

A

= relatively elevated pressure in hepatic portal venous system
clinically significant if > 10mmHg
Clinical effects
- ascites (serum - ascites albumin gradient > 11g/L)
- porto-systemic shunts - varices
- decompensation
Managed by
- salt restriction
- diuresis
- NSBB - carvedilol / propanolol
- TIPSS

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17
Q

Hepatorenal syndrome

A

renal failure - infrarenal vasoconstriction, splanchnic vasodilation, pro-inflammatory, abnormal tubular electrolyte handling leading to tubular damage
HRS-AKI
- cirrhosis iwith asicate
- AKI (ICA 1-3)
- Absence of shock and nephrotoxins
- no response to 2 consecutive days of diuretic withdrawal and volume epxnaion
- no signs of structural kidney disease
Treatment
- Noradrenaline / terlipressin, albumin, treat underlying infections, RRT

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18
Q

SBP

A

bacterial infection of ascitic fluid in absence of surgically testable cause
decompensation, pain, fever, worsening distension, shock, AKI
ascite neutrophils > 250
culture +ve 40% - E.Colo
Broad spectrum abx, repeat paracentesis after 48hr
drain ascites
albumin prevents AKI (Sort et al)

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19
Q

Scoring systems in chronic liver disease

A

MELD
Child - Pugh (ascites, INR, encephalopathy, bilirubin, albumin) 12mo survival
Clif-C-ACLF - 28d mortality (organ dysfunction)

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20
Q

Futility in ACLF

A

EASL suggest withdrawal of ICU
- 7 days after diagnosis and adequate treatment
- >4 organ failures (CLIF-C-ACLF > 64)
- Liver transplant contraindicated

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21
Q

Diarrhoea definitions

A
  • 3+ loose / liquid stools / day
  • 200g + stool / day
  • 250ml + stool / day
  • Bristol stool chart 5-7
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22
Q

Diarrhoea on critical care

A
  • infection - cross infection / contamination
  • electrolyte imbalance
  • fluid imbalance
  • nursing workload
  • skin breakdown
  • antimicrobial stewardship
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23
Q

Diarrhoea classification

A

Mechanism - secretory, osmotic, motoric, exudative
duration - acute < 2 weeks chronic > 4 weeks
Aetiology
- infectious
- bacterial c.diff, salmonella, shigella, e.coli, campylobacter
- viral - norovirus, rotavirus, adenovirus
- non-infectious
- IBD
- pancreatic insufficiency
- short bowel
- food / feeding - intolerances, osmotic
- medication related - antibiotics, pro kinetics, laxatives, chemo/radiotherapy

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24
Q

Mechanisms of antibiotic associated diarrhoea

A
  • direct pro kinetic effect
  • microbial modification - excess carbohydrates
  • unmetabolised bile salts
  • colitis from bacterial overgrowth e.g. c diff
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25
Q

Management of ICU patient with diarrhoea

A
  • infection screening / prevention
  • correction of underling cause ? gut perfusion ? medications
  • adjust feed e.g. reduce rate, fibre, osmolality
  • Fluid balance and replacement
  • Electrolye monitoring and replacement
  • Skin / barrier protection e.g. bowel management system
  • antidiarrhoeal medications
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26
Q

C.difficile

A
  • gram positive spore forming anaerobe
  • severe colitis and comlications
  • toxin producing - A = intestinal permeability B = colon inflammation
    risk factors
  • Abx - co-amox, clina, cephalopsporins
  • PPI
  • Age > 60
  • chronic care
  • exposure
    Diarrhoea –> stool test
  • GDH antigen +ve and toxin +ve = active c.diff
  • both negative = no c.diff
  • antigen +ve means c.diff in bowel but if toxin -ve not causing infection
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27
Q

C.diff severity

A

Mild
- WCC normal and < 3 loose stool / day
Moderate
- WCC raised but less than 15
- 3-5 stool
Severe any of
- WCC > 15
- Creatinine > 50% baseline
- temperature > 38.5
- severe colitis on imaging
Life thretaing
- megacolon
- hypotension
- ileus

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28
Q

C.diff management

A

enteral abx
- Vancomycin PO 125mg ads
- fidaxomicin 2nd line
- severe - Vanc 500mg qds + metronidazole
10 day treatment
faecal transplant, ivies

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29
Q

Ulcerative Colitis

A

Inflammatory bowel disease characterised by inflammation starting vitally, continuous extension proximally
complications - perforation, adenocarcinoma, haemorrhage, megacolon
Acute severe = truelove witts
- > 6 bloody stool / day
- 1 of fever, HR > 90 Hb < 105, CRP > 30
treatment = steroid, 2nd line, bloods, stool mc/s, sigmoidoscopy
response = < 4 stool, no rectal bleeding
surgical review if continued systemic toxicity, toxic megacolon > 8 stool / day

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30
Q

Crohns disease

A

chronic complex GI inflammatory condition
variable onset and location
skip lesions, ill involvement, granulomatous inflammation
complications - perforation, fistulas, strictures

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31
Q

IBD immunosuppression

A
  • 5-ASA - mesalazine (nephrotoxicity)
  • Thiopurines - azathioprine (myelotoxicity, hepatotoxicity)
  • steroids
  • Anti-TNF - infliximab, adalibumab
  • Anti-metabolite - methotrexate (GI, hepatoxicitity, pneumonitis)
  • calcineurin inhibitors - ciclosporin (nephrotoxicity)
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32
Q

HALT-IT trial

A

TXA bolus and infusion in acute UGI bleed
No difference in mortality, rebleeding, transfusions
Significantly higher VTE

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32
Q

Re-feeding syndrome

A

acute metabolic derangement with electrolyte and fluid abnormalities occurring upon reintroduction of nutrition after period of starvation
metabolic abnormalities include
- hypophosphataemia (phosphorylation of glucose)
- hypomagnaesaemia (cell uptake)
- hypokalamiea (rapid cell uptake (insulin))
- glucose imbalance
- thiamine deficiency (cofactor in glycolysis)

32
Q

Pathophysiology of refeeding syndrome

A

Starvation
- catabolic state - gylogenolysis gluconeogenesis, protein catabolism
- overal depletion of protein, carbohydrate, fat, minerals, electrolytes
refeeding
- fluid, salt, carbohydrate intake
- FFA / ketone –> carbohydrate metabolism
- insuline secretion
- protein, fat, glycogen synthesis
- intracellular uptake of glucose, K, Mg, Pho
- thiamine utilisation
- intracellular compartment depletion - wide concentration gradient - rapid depletion of extracellular ions

33
Q

risk factors

A

One of
- BMI < 16
- 15% weight loss
- 10 days of starvation
- prexisting low K / Phos / Mg
Two of
- BMI < 18
- 10% weight loss
- 5 days starvation
- alcoholism

34
Q

PATEINT GROUPS AT RISK OF MALNUTRITION

A

Reduced intake
- anorexia nervos
- social deprivation / homelssness
- alcoholism / substance addition
- malignancy
- post-operative
Excess loss / decreased absorption
- vomiting. diarrhoea/ obstruction
- pancreatitis
- GI inflammation
- bariatric surgery

35
Q

Prevention / treatment refeeding syndrome

A
  • screening
  • correct underlying risk e.g. hypo K etc
  • commencement of lower feed rates (10kcal / kg/ day, 5 if extreme)
  • correction of electrolytes
  • vitamin supplements - thiamine
  • monitoring electrolytes > daily, glucose hourly
  • cautious fluid balance
36
Q

Endogenous toxins accumulating in liver failure

A
  • bilirubin
  • bile salts
  • lactate
  • ammonia
37
Q

extracorporeal liver support

A

extracorporeal circuit used to prevent toxin build up and injury in liver failure
- bioartifical liver support - hepatocytes incorporated into plasmaphoresis
- MARS - molecular adsorbent recirculation system - extracorporeal albumin dialysis. ultra filtrate exposed to albumin rich solution across a membrane - albumin bound substances move down concentration gradient/ ultra filtrate then then conventional dialysied.
May be indicated ALF - alcoholic hpatitis, PGD, progressive jaundice

38
Q

P-Possum

A

Age
comorbidities - heart failure, dyspnoea
vitals - hr, bp, gcs
bloods - hb, wcc, na, k, urea
ecg
surgical finding - complex major, blood los, contamination, cancer

39
Q

Splenic laceration

A

laceration / haematoma
1 - < 1cm / subscapular < 10%
2 - 1-3cm / 10-50%
3 - > 3cm / > 50%
4 - 25% devascularisation, any vessel injury
5 - any vascular injury, bleeding into peritoneum

40
Q

overwhelming post splenectomy infection

A

encapsulated bacteria
< 1 week to 20 + years post splenectomy
rapidly fatal, prophylactic abx / vaccines reduced incidence

41
Q

acute pancreatitis scoring systems

A

Apache II and BISAP best at predicting severity
Glasgow
Ranson
Revised Atlanta criteria
- mild - no organ fialure, no local or systemic complications
- moderate - transient organ failure, local or systemic complications
- severe - persistent organ failure
Peripancreatic collections - acute necrotic collection / wall off necrosis
Balthazar CT sevreity

42
Q

Ileus

A

slowing of gi motiliety without mechanical obstruction
Gi causes - post-op, peritonitis, pancreatitis, ischaemia
metabolic - hypokalamiae, hyponatraemia, uraemia
medications - opioids, smootjh muscle relaxants

43
Q

ileus on critical care

A

detection - gastric aspirates
avoid aspiration - avoid lying flat
GI decompression - ryes tube, trophic feed, IV hydration
treat underlying cause - review opioids, rule out obstruction
supporitve care - PN if prolonged
prokinetics
reduce feed rate

44
Q

necrotising fasciitis

A

severe infection of subcutaenous tissue - superficial and deep fascia and subdermal fat.
1- polymicroial - mixed anaerobes and aerobes
2 - monomicrobial Group A strep, staph aureus
3- gram negative
4 - trauma associated

infection spread through fascial planes. local ischaemia, necrosis, thrombosis and toxin release

45
Q

Boerhaave syndrome

A

spontaneous rupture of oesophagus
sudden increase in oesophageal pressure (vomiting, straining) combined with negative intrathoracic pressure leads to tear and passage of GI secretions and air into mediastinum
similar picture with iatrogenic leak (endoscopy), trauma, perforation from caustic substances
Macklers triad - subcutaneous emphysema, chest pain, vomiting

46
Q

Boerhaave investigations

A

CXR - PTX, widened mediastinum, left pleural effusion
CT chest - leak site, extent, inflammation, abscess
OGD
pleural tap pH < 6, frank undigested food

47
Q

Boerhaave complications

A

respiratory failure - pleural effusion, empyema, ards
mediastinitis
subcutaneous emphysema
tamponade
death

48
Q

Boerhaave management

A

early intervention - primary repair, controlled fistula, resection, stent placement
fluid management
analgesia antibiotics
feeding - avoiding blind NG insertion
likely to require prolonged organ support, may need cervical oesophagostmy and feed jej

49
Q

oesphagectomy

A

excising portion of oesophagus with anastomosis in mediastinum - gastric conduit
tricky access - thoracic and abdominal
Ivor lewis - right thoracotomy, midline laparotomy (or rooftop)
minimally invasive - thoracoscopic , laparoscopic
trandiaphrgamatic, transmittal

morbidity and mortality - comorbid, late presentation, advanced age
anastamosis vulnerable as formed at extrene end of foregut blood supply

50
Q

critical care management post-oesophagectomy

A
  • anastomotic protection - avoid NIV, enteral feed via tube placed in theatre
  • optimise perfusion - normovolaemia, appropriate BP
  • PPI
  • vigilant monitoring
  • analgesia - thoracic epidural
  • ERAS
51
Q

complications post-oesophagectomy

A
  • respiratory - recurrent LN palsy, air leak, pneumonia, ARDS
  • CVS - AF common
  • GI - ileus, leak (first 5 days typically)

Leak
- conservative - NBM, alternative nutrition, antibiotics, chest phusio
- radiological drainage of collections
- surgical exploration

52
Q

AAA

A

dilation of abdominal aorta > 3cm
asymptomatic / screened
pulsatility / mass
abdo–>back pain
rupture - pain, shock, cardiac arrest
- CT angio
- Ddx ACS, ureteric colic

53
Q

ruptured AAA management

A
  • haemodynamic stabilisation - 1:1 transfusion ,permise hypotension
  • management of coagulopathy
  • MDT discussion - operative or not
  • operative - EVAR vs open

increased mortality
- severe haemodynamic instability, cardiac arrest, LOC, renal impairment
- intraoperative - intraperitoneal rupture, total operating time
- postoperative - MOF, bleeding, CVA

54
Q

Repair prognosis

A

rupture
- open - 50% in hospital mortality. nearly 100% if CPR pre-op
- EVAR - 20% in hospital mortality - likely more stable if able to have CT A, patient selection
elective
- 7% mortality in comorbid
- 2% in fit

EVAR vs Open in rupture - 30 day mortality no difference but LA for EVAR best mortality

55
Q

EVAR vs Open AAA

A
  • EVAR - shorter LOS, lower immediate risk, avoid complications of open but risk of endoleak
  • Open - not all suitable for EVAR
56
Q

complications of AAA repair / rupture

A

hypoperfusion
- ACS
- AKI
- CVA
- spinal cord
- bowel ischaemia
- lower limb ischaemia
recovery
- pain
- respiratory failure
- massive transfusion
surgical
- endoleak
- distal embolisation
- infection
- occlusion

57
Q

critical care management

A
  • supportive care
  • optimise haemodynamics and normothermia
  • analgesia..
  • monitoring for complications - renal, spinal cord, compartment syndromes
  • treatment of complications - RRT, spinal drain, PN
58
Q

Compartment syndrome

A

process in which pressure within a body compartment rises enough to restrict perfusion and viability of contents of that compartment
- limb
- abdominal
(orbital, cranial, cardiac)

59
Q

Pathophysiology of compartment syndromes

A

Perfusion pressure = MAP - compartment pressure
- inadequate MAP - shock, elevation
- increased compartment pressure
- increased content - bleeding, swelling, inadequate drainage
- decreased compliance - scarring, tight dressing, surgical closure
tissue oedema, necrosis worsens compartment perfusion

60
Q

Intra-abdominal compartment syndrome

A

intra abdominal hypertension is IAP > 12
1 - 12-15
2- 16 - 20
3 - 21-25
4 - 26 +
ACS = IAH 20mmHg + organ dysfunction
causes - severe acute pancreatitis, post-op AAA rupture

61
Q

Complications of abdominal compartment syndrome

A

AB - reduced FRC, ventilatory compromise, aspiration risk
C - increased afterload, reduced preload, reduced CO
D - increased ICp
G - ischaema, ileus, translocation of bacteria
F - obstructive uropahty, ptrtrnlAKI, RAS activation

62
Q

management of abdominal compartment syndrome

A

> 30mmHG strong consideration info laparotomy
stepwise
- increase MAP fluid, basoactives
- improve compliance - deep sedation analgesia, NMB
- reduce contents - NG, rectal tube, reduce enteral feed, stop enteral feed
- laparotomy

63
Q

intestinal failure

A

reduced function of gut leading to impaired absorption of micro,macronutrients and water
can be classified by nutritional support - mild = oral supplement mod = enteral severe = PN
Causes
- acute - bowel obstruction, fistula, ileus, ischaemia
- chronic - IBD, enteritis, short bowel syndrome

64
Q

short bowel syndrome

A

post surgical syndrome where length of bowel < 2m meaning nutritional supplementation is likely to required
- jej-colon
- jej-ileum
- jejuonsotomy
surgery resulting in short bowel
-crohns
- SMA thrombosis
- irradiation damage

weight loss, prerenal failure, confusion, renal stones, diarrhoea
aim of treatment to maintain nutritional requirements, reduce complications, use oral and enteral nutrition where possible

65
Q

intestinal resection

A
  • dsmotility
  • adhesions
  • water and salt loss
  • malaborption (fat and fat soluble vitamins)
  • hypomagnaesaemia, hypocalcaemia
66
Q

Flap surgery

A

provide reconstruction and cosmesis for wound coverage. commonly breast and orofacial
free flap - completely disconnected and anastomosed at new site. DIEP for breast, TRAM, radial forearm
pedicle - own arterial and venous supply. pec major myocutaneous

67
Q

concerns in free flap patients

A
  • viability , microvascular anastomoses.
    denervation - loss of sympathetic tone
    compromised lympahetics
    underlying pathology
68
Q

flap viability

A

primary icshaemia - cessation of blood flor during flap transfer. related to duration of ischaemia
repercussion - vessels unclamped - ischaemia/reperfusion injury
secondary ischaemoa - after flap transfer - arterial thrombosis, venous congestion

critical care - hagan pouseille
- avoid vasocsontrction (temperature, normbocolaemia, analgesia)
- DP - low SVR, adequate perfusion pressure, adequate drainage
- viscosity - Hct 0.3

69
Q

flap failure

A
  • anastomotic breakdown
  • vasospasm
  • thrombosis
  • compression
  • edema
    monitoring
  • dopplers
  • flaps obs - CRT, temperature, colour, bleeding on pinprick
70
Q

Admission of transplant patients to critical care

A
  • immediate post-op
  • early and late complications
  • complications of immunosuppression
  • relapse of underlying disease
  • unrelated conditions
71
Q

challenges

A
  • logistics of care and communication with transplant centre
  • access to records
  • complex patient with risk for organ fysfunction
  • balance of immunosuppression and infection
  • end stage vascular access
  • polyphramcy
72
Q

General post-op transplant management

A
  • analgesia
  • VTE
  • graft optimisation - adequate perfusion
  • immunosuppresisio - level monitoring, steroid, abx propylaxis
  • vigilance for complications
  • cardiac - early exutubation, offload rv, low dose inotropes
  • lung - LPV, early extubation, fluid resriction
  • liver coagulaopathy, acid base, calcium
  • kidney - monitor UO, avoid hypovolaemia
73
Q

primary graft dysfunction

A

immediate poort function of transplanted organ
organ specific insufficiency
may be related to ischaemia refperfusion
- heart - LVEF despite inotropes, mechanical support
- lung - impaired oxygenation, diffuse opacities
- liver - lactateaemia, hypoglycaemia, coagulopathy
- renal - hyperkalaemia, poor UO

74
Q

immunosuppressants

A
  • steroids
  • calcineurin inhiitors
  • ciclosporin, tacrolimus
  • antimetabolites - azathioprine
  • mycophenalate
  • biologics
75
Q

Vitamins

A

Organic compounds which are required in small amounts to carry out essential body processes, can’t be manufactured therefore must be ingested
Fat soluble - A D E K
Water soluble - B C

76
Q

specific vitamins

A

A - immune, vision
B2 (riboflavin) - antioxidante, red cell production, metabolism. deficiency - stomatitis
B3 - niacin - metabolic, skin, cns function. deficiency = pellagra (diarrhoea, dermatitis, dementia)
B9 - folate - cns, red cell, Dan and ran. glossitis, diarrhoea, anaemia
B12 - cobalamin - dear, RNA, red cell. pernicious anaemia
vitamin c - wiybdm cikkageb. weakness, weight loss, scurvy

77
Q

Thiamine deficiency

A

B1 (thiamine)
- coenzyme in carbohydrate metabolism and ATP production (carb metabolism, pyruvate dehydrogenase –> AcetylCoA

Dry Beri-beri - wasting, paralysis, ataxia
Wet beri beri - high output cardiac failure, peripheral oedema
Wernickes encephalopathy - confusion, ataxia, ophthalmoplegia
Korsakoff - severe memory impairment

78
Q

more vitamins

A

Vitamin D - calcium absorption, bone strength
Vit K - coagulation, bone metabolism
Selenium - T4–> T3
Zinc - hormone, immune
Copper - metabolic, antioxidant

FFICM (14 decks)

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