Gastro Flashcards
What are the indications for liver transplant?
Survival > 50% 5yrs post-transplant
- MELD > 15
- LIver disease with > 50% mortality at 2yrs if not transplanted
- Diuretic-resistant ascites
- Recurrent hepatic encephalopathy
- Recurrent SBP
- Recurrent or persistent GI haemorrhage
- Intractable cholangitis
- Hepatopulmonary syndrome
- Portopulmonary HTN
- Metabolic syndromes (with severe or life-threatening symptoms) that are curable with liver transplantation (eg. familial amyloidosis, urea cycle disorders, oxalosis)
- Polycystic liver disease with severe or life-threatening symptoms
- Intractable itch secondary to cholestatic liver disease
- Hepatoblastoma
What are the contraindications to liver transplantation?
Active illicit substance misuse AIDS Extrahepatic malignancy Uncontrolled sepsis Extrahepatic organ failure (lungs, heart). Pulmonary pressure > 50mmHg absolute contraindication. Splanchnic thrombosis extending to SMA
What are the management principles in cirrhosis?
- Weight loss if overweight => decreased mortality and HCC risk
- Late evening high protein meal => reduced muscular catabolism
- Coffee => 2 cups daily reduced all-cause mortality, fibrosis and HCC
- Dark chocolate and Vit C => reduces post-prandial rise in HPVG
- No EtOH. Baclofen if alcoholic + cirrhotic.
- Smoking cessation => less fibrosis in Hep C, NASH, PBC. Improved post-transplant morbidity and mortality.
- Vaccination: Hep A, Hep B, influenza, pneumococcus as early as possible
Portal HTN
- Defined as HVPG > 5mmHg. Varices develop when HVPG > 10mmHg. Bleeding if HVPG > 12mmHg
- SAAG ≥ 11 also defines portal HTN
- Na restriction to <2g/day
- Spironolactone 100mg/d (max 400mg/d) +/- frusemide 40mg/d (max 160mg/d)
- Non-selective beta blockers (propranolol or carvedilol) to target BP<60. Ensure HR>50 and systolic BP>90. Also reduces incidence of spontaneous bacterial peritonitis. Contraindicated if refractory ascites, SBP, severe alcoholic hepatitis, or BP < 100 systolic.
- Midodrine may increase U/O, urinary Na excretion, and MAP in those with stable hypotension.
- Fluid restrict if Na < 120 (intake < urine output)
Varices
- Banding if variceal bleeding
- TIPSS if recurrent GI bleeds despite banding
Ascites
- Large volume paracentesis with 8g/L albumin IV (20g in 100mL of 20%) when drainage > 5L
Spontaneous bacterial peritonitis phrophylaxis
- Secondary prophylaxis if previous SBP.
- Bactrim DS 1 daily 1st line, norfloxacin 2nd line
- Primary prophylaxis if ascites protein < 15/g AND renal impairment (Cr ≥ 110 or Ur ≥ 8.9 or Na ≤ 130) or liver failure (Child-Pugh ≥ 9 and bili ≥ 50)
Encephalopathy
- Lactulose and rifaximin
Meds
- Avoid NSAIDs, ACEIs, aminoglycosides (renal impairment).
- PPIs may increase risk of SBP.
- Antihypertensives should cease (increased survival if systolic BP>82)
- Limit paracetamol to 2g/d
- If sedatives are necessary, use either loraz or oxaz (short acting); or trazodone 100mg nocte.
- Use statins in NAFLD - mortality benefit
Transplantation discussion
Consider when MELD ≥ 17
Which patients with chronic HBV infection should be treated?
- Adults with immune-active CHB (HBeAg- or HBeAg+), defined by ALT >2 times ULN or evidence of significant histological disease and HBV DNA >2000 IU/mL (HBeAg negative) or >20,000 IU/mL (HBeAg positive)
- Persons with immune-active CHB and cirrhosis if HBV DNA >2000 IU/mL, regardless of ALT level
- Persons ˃40 years with normal ALT and elevated HBV DNA (≥1,000,000 IU/mL) and liver biopsy showing significant necroinflammation or fibrosis
Wha are the stages of chronic HBV infection?
Immune tolerant => immune active => inactive carrier => immune escape/reactivation
Which urinary markers can be used to distinguish between hepatorenal syndrome and ATN?
NGAL and IL-18 (elevated in ATN)
What are the pharmacological treatment options in hepatorenal syndrome?
Albumin 1g/kg/d + terlipression OR
Albumin 1g/kg/d + octreotide + midodrine
CRRT
Liver-kidney transplant
What do the MELD and UKELD scores predict?
3 month and 1 year mortality respectively
What is the initial diuretic regime in cirrhosis with ascites?
Spironolactone 100mg daily + frusemide 40mg daily
Combined Rx better than sequential Rx
What assessment tools are available in Crohn’s Disease?
CDAI - Crohn’s Disease Activity Index (symptomatic)
CDEIS - Crohn’s Disease Endoscopic Index of Severity (inflammation assessment)
CRP and faecal calprotectin - inflammation
PROSPECT - web-based tool to predict risk of developing CD-related complications. Most important parameters are 1) disease location, 2) depth of lesions, 3) disease extent, and 4) young age of pt.
Treat early with biologics - better outcomes
How do you decide between biologic agents in Crohn’s Disease?
Anti-TNF
- Best results on mucosal healing
- Preferred in spondyloarthropathies or uveitis
- If deep fistulising disease, use anti-TNF + DMARD
Anti-integrin (vedolizumab)
- At 6-12 months, mucosal healing very good
- Preferred in concurrent skin disorders
Anti-IL12/23 (ustekinumab)
- Preferred in concurrent psoriasis
What conditions are associated with coeliac disease?
- Aphthous ulcers and angular cheilitis
- Dry skin, hair and nails
- Dental problems: thin enamel
- Neurological: ataxia, polyneuropathy, epilepsy
- Cardiac: pericarditis, cardiomopathy
- Fatty liver
- NHL, particularly affecting the intestines
- Dermatitis herpetiformis
- Osteoporosis
- IgA deficiency
- Hyposplenism
- Recurrent miscarriages
Where is Fibroscan validated? What value excludes cirrhosis?
Validated in Hep C, pre-treatment
Elastography < 12.5kPa => excludes cirrhosis
What APRI score excludes cirrhosis?
APRI < 1.0 => not cirrhosis
What is the main micronutrient deficiency in gastric bypass patients?
Iron deficiency
