GASTRO/GENSURG
LIVER FAILURE/ENCEPHALOPATHY
Questions mostly confused patient with chronic liver disease
PromptComponents of Child-Pugh Score
ResponseABCDE
Albumin (1 >35, 3<30)
Bilirubin (1<34, 3>51)
Coags - INR (1 <1.7, 3>2.3)
Deluge - Ascites (1 absent, 2 slight, 3 moderate)
Encephalopathy (none =1, Advanced =3)
A = 5-6 - 1 yr survival = 100%
B=7-9, - 1 yr survival 80%
C >=10 - 1 yr survival 45%
Albumin (1 >35, 3<30)
Bilirubin (1<34, 3>51)
Coags - INR (1 <1.7, 3>2.3)
Deluge - Ascites (1 absent, 2 slight, 3 moderate)
Encephalopathy (none =1, Advanced =3)
A = 5-6 - 1 yr survival = 100%
B=7-9, - 1 yr survival 80%
C >=10 - 1 yr survival 45%
PromptPoor prognostic factors associated with fulminant liver failure
ResponseAge <10, >40
Bilirubin >300
PT >100
Longer duration of jaundice
Bilirubin >300
PT >100
Longer duration of jaundice
PromptStigmata of chronic liver disease
ResponsePalmar erythema
Spider naevi
Jaundice
Ascites
Splenomegaly
gynaecomastia
Spider naevi
Jaundice
Ascites
Splenomegaly
gynaecomastia
PromptCauses of exacerbation of chronic liver disease and how to confirm this (may be worded precipitants of hepatic encephalopathy)
ResponseSepsis/SBP - Ascitic tap for organisms/WCC
UGI Bleed - PR for malena
Alcohol (intox or withdrawal) - Serum alcohol level, or other drug ingestions (Eg: benzo’s) - urine drug screen
Toxins - Paracetamol, sedatives, diuretics - Paracetamol level
Mushrooms (Knowing that chick who killed her church group with death caps)
Hypoglycaemia - BSL
Vascular (portal vein thrombosis or hepatic vein thrombosis= Budd Chiari syndrome) - US/CT abdo with contrast
Head trauma (eg: Subdural) - CTB (After acute brain injury, the chemokine expression by the liver results in neutrophil recruitment and hepatic damage, contributing to multi-organ dysfunction.)
Medication non compliance
High protein diet
Many more
UGI Bleed - PR for malena
Alcohol (intox or withdrawal) - Serum alcohol level, or other drug ingestions (Eg: benzo’s) - urine drug screen
Toxins - Paracetamol, sedatives, diuretics - Paracetamol level
Mushrooms (Knowing that chick who killed her church group with death caps)
Hypoglycaemia - BSL
Vascular (portal vein thrombosis or hepatic vein thrombosis= Budd Chiari syndrome) - US/CT abdo with contrast
Head trauma (eg: Subdural) - CTB (After acute brain injury, the chemokine expression by the liver results in neutrophil recruitment and hepatic damage, contributing to multi-organ dysfunction.)
Medication non compliance
High protein diet
Many more
PromptCauses of confusion in liver patients (non hepatic encephalopathy)
ResponseAlcohol/Drugs
Head injury
Electrolyte disturbance
Endocrine - Hypoglycemia
Head injury
Electrolyte disturbance
Endocrine - Hypoglycemia
PromptInvestigations in hepatic encephalopathy/liver failure
(this was a 12 mark q!)
(this was a 12 mark q!)
ResponseLFT’s - Hepatic failure (ALT/AST high), non obstructive pattern, Elevated bilirubin, low albumin.
BSL - ? Hypoglycaemia secondary to fulminant liver failure
Sodium - Hyponatraemia as cause of confusion - ? due to chronic liver disease/diuretics
CTB - High chance of ICH due to coagulopathy from chronic liver disease (or cerebral oedema)
Ascitic fluid tap - Exclude SBP as precipitant for hepatic encephalopathy
FBC - Anaemia from GI bleed as cause for hepatic encephalopathy, Thrombocytopaenia common
Ammonia level - confirm hepatic encephalopathy as cause for confusion
Paracetamol level - ? Need for NAC
Coags - define extent of coagulopathy/liver dysfunction
Complications - pleural effusion on CXR
Hepatitis serology - look for etiologic causes for liver failure
(other tests for sepsis - CXR, Urine, blood cultures if febrile. Crossmatch if bleeding)
BSL - ? Hypoglycaemia secondary to fulminant liver failure
Sodium - Hyponatraemia as cause of confusion - ? due to chronic liver disease/diuretics
CTB - High chance of ICH due to coagulopathy from chronic liver disease (or cerebral oedema)
Ascitic fluid tap - Exclude SBP as precipitant for hepatic encephalopathy
FBC - Anaemia from GI bleed as cause for hepatic encephalopathy, Thrombocytopaenia common
Ammonia level - confirm hepatic encephalopathy as cause for confusion
Paracetamol level - ? Need for NAC
Coags - define extent of coagulopathy/liver dysfunction
Complications - pleural effusion on CXR
Hepatitis serology - look for etiologic causes for liver failure
(other tests for sepsis - CXR, Urine, blood cultures if febrile. Crossmatch if bleeding)
PromptUltrasound findings concerning in liver failure
ResponseHepatic paenchymal architecture - Eg: Cirrhosis
Exclusion of biliary tract obstruction (non dilated intrepatic ducts and CBD)
Ascites (Portal Htn, Potential for tap/drainage/SBP)
Splenomegally - indicator of portal hypertension
Exclusion of biliary tract obstruction (non dilated intrepatic ducts and CBD)
Ascites (Portal Htn, Potential for tap/drainage/SBP)
Splenomegally - indicator of portal hypertension
PromptTreatment of liver failure
ResponseFrusemide, spironolactone, Na+ restriction
lactulose -> increases ammonia elimination (20-30 mL TDS)
Metronidazole -> alter gut flora to decrease ammonia production (or Rifaxamin 550 mg BD)
?albumin infusion (improve haemodynamics, especially if draining ascites)
TIPS procedure - transjugular intrahepatic portosystemic shunt
lactulose -> increases ammonia elimination (20-30 mL TDS)
Metronidazole -> alter gut flora to decrease ammonia production (or Rifaxamin 550 mg BD)
?albumin infusion (improve haemodynamics, especially if draining ascites)
TIPS procedure - transjugular intrahepatic portosystemic shunt