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FFICM > OSCE - Liver > Flashcards

OSCE - Liver Flashcards

1
Q

How do you do an ascitic tap

A

Consent if possible
Use percussion or ultrasound to find best position
Position supine or lateral decubitus

Asepsis - sterile gown, gloves, facemask, chlorhex to skin
Drape and US probe cover

Infiltrate skin with lignocaine

20g needle on a 20ml syringe perpendicular to skin, aspirate

40mls for tests

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2
Q

Tests to do with ascites

A 
Cell count and differential
MC&C
LDH
Albumin
Amylose
Glucose
Cytology
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3
Q

SBP diagnosis on ascites

A

Polymorphonuclear cells (PMN) >250 PMN/mm3

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4
Q

How would TB look in ascites

A

Large lymphocyte count instead of PMN

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5
Q

Once SBP has been diagnosed, what other Ix might you do

A

Renal biochemistry

Abdo ultrasound

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6
Q

Causes of an AKI in liver disease

A

Pre-renal - hypoperfusion, sepsis, cardiac and hepatic failure

Renal - nephrotoxic drugs, intirinsic disease

Post - renal obstruction

HRS

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7
Q

Mortality of type 1 HRS

A

90%

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8
Q

What features suggest synthetic failure

A

Low albumin

Raised INR

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9
Q

Management of refractory ascites

A 
Sodium restriction
High dose furosemide and spironolactone
Beta blockers for portal hypertension
TIPS
Liver transplant
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10
Q

Triad of acute liver failure

A

Jaundice

Encephalopathy

Coagulapathy

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11
Q

Classifcation of acute liver failure

A

O Grady - Interval from jaundice to encephalopathy:

Hyper acute - less than 7 days

Acute 1 to 4 weeks

Sub acute 4 weeks 6 months

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12
Q

Differentials of acute liver failure

A

Drug induced - paracetamol
Viral Hep ABC,E

Alcoholic Hep
Auto immune hep

Miscellaneous- ischaemic hep, Budd Chiari, HELLP, fatty liver, Wilsons

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13
Q

Budd chiari presentation

A

Abdo pain
Ascites
Liver enlargement

Due to hepatic venous obstruction

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14
Q

Investigations of acute liver failure

A 
FBC, U&E, LFT
CLOTTING STUDIES
Paracetamol/salicylate level
GLUCOSE
Lactate

ABG (lac/gluc)
Auto-immune screen - anti smooth muscle/mitochondrial
Vita hep screening

Ammonia

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15
Q

Treatment of paracetamol overdose

A

ABCDE
Establish time of ingestion
Start NAC if level is above treatment line

Correct hypoglycaemia - dextrose

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16
Q

Grading of encephalopathy

A

West Haven Scale

0 - Subclinical. Normal but minimal change in memory and concentration

1 - mild confusion, low attention, slow to do tasks

2 - Drowsiness, lethargy, gross deficit in task. Persona change, disorientated

3 - Somnolent but reusable, can’t do mental task, confusion, aggression

4 - coma, posturing

17
Q

Managing cerebral oedema in encephalopathy

A 
Head up tilt
Loose ties
Normocapnoea
Maintain CPP 90
ICP monitor
Normoglycaemia
?refer
18
Q

Causes of Upper GI bleed

A

Peptic ulcer (gastro/duodenal)

Oesophagitis, gastritis, duodenitis

Varices

Mallory Weiss

Angiodysplasia

Aorta-enteric fistula

Malignancy (oesophagus/gastric)

19
Q

History and examination in cirrhosis plus Upper GI bleed

A 
History - confirm events 
Past Med Hx - medications (NSAIDs, Steroids, anticoagulants, platelets
Alcohol use
Previous bleeds
Liver disease status
Viral status

Examine for chronic liver disease, assess abdomen, consider PR

Ix - LFTs, CT/US, old endoscopy

20
Q

Treatment of clotting in cirrhosis

A

DONT - they guide synthetic function

Unless doing a procedures

FFP if INR>1.5
Platelets if <50

Massive haemorrage protocol if relevant

21
Q

Pharmacological tx of upper GI bleed

A

TERLIPRESSIN
PPI - omeprazole, Hong Kong
TXA

Broad Abx - ceftriaxone
?erythromicin for emptying

Thiamine/multivits (stop encephalopathy)

Lactulose

22
Q

How does Terlipressin work

Side effects:

A

Pro-drug of vasopressin

Acts on V1 receptors

Causes sphlanic vasoconstriction —> reduced portal flow and pressure
Lowers variceal pressure

Side effects - increase SVR, reduced CO, reduced CBF

23
Q

Tx of massive upper GI

A

Call for help - gastro, ICU, anaesthetist, haem
Activate Massive Haemorrhage Protocol

ABCDE, allow permissive hypotension
Resus with blood products
Secure airway, RSI, cricoid, monitor. PPE for bloodsplashes

Theatre, endoscopy
Sengstaken Blakemore

24
Q

Features of SBT

A

Two balloons, oesophageal and gastric

3 ports - balloons x2 and one for gastric suction

4 in Minnesota - 2 suction ports

25
Q

Set up a Sengstaken tube

A

Test inflate both balloons with 50mls air (could use a manometer)

Lube

Insert into the mouth to 50cm at level of teeth

Insert 20mls air, listen over stomach, insert 50mls. CXR to confirm

Fully deploy - 50ml blouses of air up to 250mls

Traction on a 500ml fluid bag

Note depth.

26
Q

Assess bleeding via SBT

A

Apply suction to gastric lumen and empty stomach

Lovage with 50mls and aspirate

If oesophageal - inflate to pressure of 40mmHg (sphygmomanometer)

Oesophageal need to come down for 5 minutes per hour

27
Q

Complications of SB tube

A

Aspiration
Hernia thing balloon

Perforation- gastric balloon in oesophagus

Muscosal ischaemia - excess pressure or inflated a long time

FFICM (57 decks)

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