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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
Management of ICU patient with diarrhoea
- 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
26
C.difficile
- 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
27
C.diff severity
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
28
C.diff management
enteral abx - Vancomycin PO 125mg ads - fidaxomicin 2nd line - severe - Vanc 500mg qds + metronidazole 10 day treatment faecal transplant, ivies
29
Ulcerative Colitis
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
30
Crohns disease
chronic complex GI inflammatory condition variable onset and location skip lesions, ill involvement, granulomatous inflammation complications - perforation, fistulas, strictures
31
IBD immunosuppression
- 5-ASA - mesalazine (nephrotoxicity) - Thiopurines - azathioprine (myelotoxicity, hepatotoxicity) - steroids - Anti-TNF - infliximab, adalibumab - Anti-metabolite - methotrexate (GI, hepatoxicitity, pneumonitis) - calcineurin inhibitors - ciclosporin (nephrotoxicity)
32
HALT-IT trial
TXA bolus and infusion in acute UGI bleed No difference in mortality, rebleeding, transfusions Significantly higher VTE
32
Re-feeding syndrome
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
Pathophysiology of refeeding syndrome
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
risk factors
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
PATEINT GROUPS AT RISK OF MALNUTRITION
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
Prevention / treatment refeeding syndrome
- 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
Endogenous toxins accumulating in liver failure
- bilirubin - bile salts - lactate - ammonia
37
extracorporeal liver support
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
P-Possum
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
Splenic laceration
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
overwhelming post splenectomy infection
encapsulated bacteria < 1 week to 20 + years post splenectomy rapidly fatal, prophylactic abx / vaccines reduced incidence
41
acute pancreatitis scoring systems
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
Ileus
slowing of gi motiliety without mechanical obstruction Gi causes - post-op, peritonitis, pancreatitis, ischaemia metabolic - hypokalamiae, hyponatraemia, uraemia medications - opioids, smootjh muscle relaxants
43
ileus on critical care
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
necrotising fasciitis
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
Boerhaave syndrome
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
Boerhaave investigations
CXR - PTX, widened mediastinum, left pleural effusion CT chest - leak site, extent, inflammation, abscess OGD pleural tap pH < 6, frank undigested food
47
Boerhaave complications
respiratory failure - pleural effusion, empyema, ards mediastinitis subcutaneous emphysema tamponade death
48
Boerhaave management
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
oesphagectomy
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
critical care management post-oesophagectomy
- anastomotic protection - avoid NIV, enteral feed via tube placed in theatre - optimise perfusion - normovolaemia, appropriate BP - PPI - vigilant monitoring - analgesia - thoracic epidural - ERAS
51
complications post-oesophagectomy
- 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
AAA
dilation of abdominal aorta > 3cm asymptomatic / screened pulsatility / mass abdo-->back pain rupture - pain, shock, cardiac arrest - CT angio - Ddx ACS, ureteric colic
53
ruptured AAA management
- 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
Repair prognosis
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
EVAR vs Open AAA
- EVAR - shorter LOS, lower immediate risk, avoid complications of open but risk of endoleak - Open - not all suitable for EVAR
56
complications of AAA repair / rupture
hypoperfusion - ACS - AKI - CVA - spinal cord - bowel ischaemia - lower limb ischaemia recovery - pain - respiratory failure - massive transfusion surgical - endoleak - distal embolisation - infection - occlusion
57
critical care management
- supportive care - optimise haemodynamics and normothermia - analgesia.. - monitoring for complications - renal, spinal cord, compartment syndromes - treatment of complications - RRT, spinal drain, PN
58
Compartment syndrome
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
Pathophysiology of compartment syndromes
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
Intra-abdominal compartment syndrome
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
Complications of abdominal compartment syndrome
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
management of abdominal compartment syndrome
> 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
intestinal failure
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
short bowel syndrome
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
intestinal resection
- dsmotility - adhesions - water and salt loss - malaborption (fat and fat soluble vitamins) - hypomagnaesaemia, hypocalcaemia
66
Flap surgery
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
concerns in free flap patients
- viability , microvascular anastomoses. denervation - loss of sympathetic tone compromised lympahetics underlying pathology
68
flap viability
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
flap failure
- anastomotic breakdown - vasospasm - thrombosis - compression - edema monitoring - dopplers - flaps obs - CRT, temperature, colour, bleeding on pinprick
70
Admission of transplant patients to critical care
- immediate post-op - early and late complications - complications of immunosuppression - relapse of underlying disease - unrelated conditions
71
challenges
- 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
General post-op transplant management
- 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
primary graft dysfunction
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
immunosuppressants
- steroids - calcineurin inhiitors - ciclosporin, tacrolimus - antimetabolites - azathioprine - mycophenalate - biologics
75
Vitamins
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
specific vitamins
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
Thiamine deficiency
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
more vitamins
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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