Gastrointestinal Flashcards
(135 cards)
1
Q
What is the acute abdomen?
A
A sudden, severe onset of acute abdominal pain lasting less than 24 hours
2
Q
What signs may indicate peritonitis?
A
Guarding or rigidity
Rebound tenderness
Absent bowel sounds
3
Q
What is a complication of peritonitis?
A
Spontaneous bacterial peritonitis - spontaneous infection of the ascites in cirrhotic liver disease
4
Q
What is the difference between localised and generalised peritonitis?
A
Localised - due to underlying organ inflammation such as appendicitis
Generalised - due to perforation such as peptic ulcer or ruptured appendix
5
Q
What is the foregut border and supply?
A
Mouth to the major duodenal papilla
Coeliac axis - T12
6
Q
What is the midgut border and supply?
A
Major duodenal papailla to 2/3 along the transverse colon
Superior mesenteric artery - L1
7
Q
What is the hindgut border and supply?
A
Left 1/3 along the transverse colon to the upper anal canal
Inferior mesenteric - L3
8
Q
What is a hernia?
A
Protrusion of a viscus or part of a viscus through a defect in the abdominal wall
9
Q
What is the process of a hernia becoming strangulated?
A
Bowel through narrow neck may cause swelling and so an interrupted blood supply.
Capillary pressure increases - leaks into hernial cavity - increases the pressure - increased swelling and pressure - venous outflow reduced - stasis of blood - thrombosis - greater pressure - swelling - necrosis and death of bowel
10
Q
What is a Richter’s hernia?
A
Strangulation of the bowel without obstruction.
One wall of the bowel is protruding through the weakness in the abdominal wall. Bowel contents can still pass through but the bowel can still become ischaemic and die
11
Q
What are the borders of the inguinal cavity?
A
Roof - M - Transversus abdominis muscles and internal oblique muscle
Anterior - A - External and internal oblique aponeurosis
Lower - L - lacunar ligament and inguinal ligament
Posterior - T - Conjoint tendon and transveralis fascia
12
Q
What are the types of oesophageal cancers and their associations?
A
Squamous - Can affect anywhere in the oesophagus, but more common in upper and middle 1/3 - associated with smoking and drinking, HPV, achalasia
Adenocarcinoma - Affects lower 1/3. GORD and obesity
13
Q
What antibiotics might you give early in acute peritonitis?
A
IV metronidazole 500mg + Cefuroxime 750mg
14
Q
What are the causes of upper GI perforations?
A
INVITED Infections - H.pylori Neoplasm - Gastric carcinoma Vascular - inflammatory or AI Iatrogenic - ERCP or OGD Traumatic - stab wound Endocrine - Zollinger Ellison syndrome Drugs - NSAIDs Chemicals - batteries
15
Q
What organisms are commonly involved in intra-abdominal abscesses?
A
Anaerobes, E.coli, klebsiella, enterococcus
16
Q
What is the definitive management for an intra-abdominal abscess?
A
IV antibiotics if septic - Amox + met + gent
Radiologically guided US or CT drainage
Open surgical drainage if ^ not possible or safe
17
Q
What are the first line antibiotics in spontaneous bacterial peritonitis?
A
IV Tazobactam with piperacillin 4.5g/8h
18
Q
What triad may be seen in cholangitis? (Inflammation of the biliary tree)
A
Charcot’s triad - Jaundice, RUQ pain, fever
19
Q
What pentad may indicate Acute suppurative Cholangitis?
A
Reynold’s - Jaundice, Fever, RUQ pain, hypotension, confusion
20
Q
What is Mirizzis syndrome?
A
Obstructive jaundice
Caused by extrinsic compression of an extra hepatic biliary duct from one or more calculi in the cystic duct or GB. Can present with biliary duct dilation and can mimic e.g. cholangiocarcinoma
21
Q
What type of pancreatic cancer is most common?
A
Adenocarcinoma of the head of the pancreas
22
Q
What tumour marker indicates pancreatic cancer?
A
CA19-9
23
Q
What might cause raised amylase?
A
Acute pancreatitis Ectopic pregnancy Bowel perforation Mesenteric ischaemia DKA
24
Q
What scale can be used to assess acute pancreatitis?
A
PANCREAS Glasgow scale/Imrie scale PaO2 < 60 Age > 55 Neutrophils (WCC >15) Calcium < 2 uRea > 16 Enzymes (LDH > 600 or ALT/AST >200) Albumin < 32 Sugar > 10
25
What are some local complications of acute pancreatitis?
```
Pancreatic pseudocyst
Pancreatic necrosis
Pancreatic abscess
Infected pancreatic necrosis
Gastric outlet obstruction
Haemorrhage
Portal vein thrombosis
```
26
What are some distant complications of acute pancreatitis?
```
Hypotension/ shock
Renal failure, liver failure, multi organ failure
Infection
Respiratory failure
Ileus
```
27
What structural changes occur in chronic pancreatitis?
Calcification, fibrosis and atrophy
28
What are some complications of chronic pancreatitis?
Ascites, Pancreatic pseudocysts, pancreatic cancer, diabetes
29
What are some causes of upper GI bleeding?
```
Mallory-Weiss tear
Oesophgeal varices
Stomach or duodenal ulcer
Stomach or duodenal cancer
Gastritis
GORD
Angiodysplasia
```
30
What score establishes the risk of having an upper GI bleed?
Glasgow-blatchford scale
| Drop in Hb, rise in urea, Bp, HR, syncope, meleana
31
How would you manage an upper GI bleed?
ABATED
A-E assessment and immediate fluid resuscitation
Bloods - FBC, Xmatch, LFTs, U&Es (Urea), CRP, INR, clotting
Access - 2 large bore cannula - for fluids, give O2
Transfuse when Hb <7-8g/dL (FFP/platlets/prothrombin complex concentrate)
Endoscopy (adrenaline injection/banding of varies/ heater probe/ sengstaken tube/ surgery)
Drugs - STOP NSAIDs and anticoagulants
32
What is first line management in acute variceal bleeding?
Resus - IV fluids, transfuse <7g/dL
*Antibiotics (Ceftriaxone or Ciprofloxacin) + Terlipressin (Vasoactive drug) EARLY
Endoscopic banding 1st line for varices
TIPS or sengstaken tube for uncontrolled bleeding
33
Dysphagia can be split into 2 main causes, what are they?
Oesophageal - inability to pass food or liquid down the oesophagus
Oropharyngeal - Difficulty initiating swallowing - coughing on swallowing, nasal regurgitation, choking
34
What are the possible causes of inability to pass solid food only down the oesophagus?
Mechanical obstruction -
Progressive? (>50? weight loss?) -- Carcinoma. (Heart burn?) - peptic stricture
Inermittent? - lower oesophageal ring dysfunction
35
What are the possible causes of inability to pass solid and liquids down the oesophagus?
Neuromuscular disorder -
Intermittent - Diffuse oesophageal spasm
Progressive - (reflux sx?) - Scleroderma. Achalasia
36
What are the possible causes of dysphasia where there is trouble initiating swallowing?
Neuro - Bulbar plasy
Muscular - Myasthenia gravis, muscular dystrophy
Structural - Thyromegaly
37
What may be the problem in a patient presenting with dysphagia who has a neck bulge and gurgling noise occurs on drinking?
Pharyngeal pouch
38
What causes corkscrew appearance on a barium swallow?
Diffuse oesophageal spams - intermittent - both solids and liquids
Usually with chest pain
Multifocal high amplitude contractions possibly due to dysfunction of the inhibitory neurones.
39
What might cause a patient to present with odynophagia, dysphagia, mouth thrush and white spots on endoscopy?
Oesophageal candidiasis - in immunocompromised patients due to candid albicans.
Tx - Fluconazole 50mg for 7-14 days
40
What is Achalasia?
Motility disorder due to progressive destruction of the ganglion cells in the myenteric plexus.
Failure of the lower oesophageal sphincter to relax and progressive failure of smooth muscle contraction
41
What investigations might you do in suspected achalasia?
Endoscopy
*Oesophgeal Manometry - Absence of peristalsis, Higher lower oesophageal resting tone and failure of the lower sphincter to relax.
Barium swallow - Bird beak appearance.
Tx - Ca channel blockers or nitrates or Laproscopic hellers myotomy or balloon dilation
42
What is a pharyngeal pouch?
Zenker's diverticulum
Uncoordinated swallowing movement cause herniation through the cricopharyngeal muscle
Chronic cough, neck lump, gurgling, hoarse voice, halitosis, aspiration, regurgitation
43
What are some ALARMing symptoms in peptic ulcer disease?
```
Iron deficiency Anaemia
Loss of weight
Anorexia
Recent onset/progressive symptoms
Melaena and coffee ground vomit - haematemesis
Dysphagia
```
44
What triple therapy is used in H.pylori?
PPi + amoxicillin + Clarithromycin or metronidazole 7 days PO
45
Give some features of diffuse gastric cancer?
Mainly affects cardia. Associated with GORD
Individuals malignant cells with mucin vacuoles (signet ring cells)
Can invade extensively but not seen well endoscopically - Linitis plastica
Mets to ovaries - Krunkenberg tumour, Mets to umbilicus - sister Mary Jospeh nodule, mets to stomach - Virchows node, mets to pouch of douglas - Blumer's shelf
46
Where does coeliac disease affect?
Small bowel - particularly the jejunum
47
What is the genetic link to coeliac disease?
HLA-DQ2/8
48
What antibodies are found in coeliac and what must you test before checking for these?
Anti-TTG - Anti-tissue transglutaminase
Anti-EMA - Anti-endomysial antibody
These will rise if the disease is active and may disappear with effective treatment
Check for an IgA deficiency
49
What are some complications of untreated coeliac disease?
```
Vitamin deficiency
Anaemia
Osteoporosis
Enteropathy associated T cell lymphoma of the intestines
NHL
Small bowel adenocarcinoma
```
50
What diseases are associated with coeliac?
```
Dermatitis herpitiformis (itchy blistering skin rash typically on the abdomen)
T1DM
IgA deficiency
```
51
What are some signs of GI malabsorption?
```
Anaemia (low Fe, B12 or folate)
Bleeding disorders (Low Vitamin K - Longer INR)
Metabolic bone disease (low Vitamin D)
Neuropathy (low Ca)
Oedema (low protein)
```
52
What is refractory coeliac disease?
Recurrent malabsorptive symptoms and villous atrophy despite being on a strict gluten free diet for at least 6-12 months in the absence of another cause of non-responsive treated coeliac disease and overt malignancy
Can try steroids - Azathioprine
53
What are some features of intestinal type gastric cancer?
Due to H.pylori
Distal stomach affected - body and antrum
Pangastritis can lead to it/ atrophic gastritis
Ulcerated growth
54
A complication of a gastrectomy is dumping syndrome, what is this?
Sudden and large passage of hypertonic gastric fluid into the small bowel causing large intraluminal fluid shifts causing nausea, diarrhoea, hypovolaemia and intestinal distention,
55
What liver function test may indicate excess alcohol?
AST:ALT ratio >1.5
56
What are some characteristic features of alcoholic hepatitis and what scoring system can be used?
Hepatomegaly ± fever ± leucocytosis ± hepatic bruit
| Glasgow Alcoholic hepatitis score - age, WCC, urea, PT/INR, bilirubin
57
What is non-alcoholic fatty liver disease?
A metabolic syndrome with problems with processing and storing energy increasing the likelihood of heart disease, stroke and diabetes
Can progress to hepatitis and cirrhosis
58
What investigations might you do in suspected NAFLD?
```
US of liver
Hepatitis B and C serology
Alpha 1 antitrypsin levels
Immunology/autoantibodies (anti-mitochondiral in PBC, Anti-smooth muscle in AI hepatitis, Anti-nuclear in SLE)
Ferritin and transferritin levels (HH)
```
59
What is acute on chronic liver failure?
When a patient with chronic liver disease such as cirrhosis has an acute decompensation due to a varity of causes such as:
Infection - SBP, pneumonia, skin infection
Hepatotoxic insult - alcohol, hepatitis, drugs
Hypoglycaemia or electrolyte disturbance
60
What are some features of acute decompensation in acute on chronic liver disease?
Encephalopathy, ascites, oedema, jaundice, fever
61
What is hepatic encephalopathy?
A neuropsychiatric disorder affecting cognitive function in acute-on-chronic liver disease
62
What clinical signs may indicate hepatic encephalopathy and what is the treatment?
Asterixis, altered conscious level
Type ! - anxiety, lack of awareness and shortened attention span
Type II - ataxia, lethargy, subtle personality changes, inappropriate behaviour
Type III - gross disorientation, confusion, seizures
Type IV - Completely unresponsive, coma
Give Lactulose (10-15ml) - binds ammonia to stool
63
In acute alcohol withdrawal when might symptoms first show?
~ 8 hours after withdrawal
| Shaking, sweating, tremor, anxiety, N&V
64
When do symptoms start to peak in acute alcohol withdrawal and what might they be? (think of severe Sx)
24-72 hours after withdrawal
| Delirium tremens, hallucinations, seizures- tonic clonic
65
What is a serious possible complication of acute alcohol withdrawal?
Delirium tremens - usually 3-4 days after withdrawal. Sudden onset confusion -
Agitation, tremor, confusion, hallucinations
altered cognition and vital signs *
Respiratory alkalosis, wernicke-korsakoff psychosis
Tx - Benzodiazepines, IV fluids, Antipsychotics
66
What syndrome occurs in acute thiamine deficiency?
Wernicke-korsakoff syndrome: Triad -
Ophthalmoplegia, ataxia (cerebellar), confusion
Diagnosis: Reduced Red cell transketolase activity
Give IV thiamine
67
What is the tumour marker for hepatocellular cancer?
Alpha fetoprotein
68
What scoring systems can be used to asses severity in cirrhosis?
LFTs often normal in cirrhosis
Childs-turcotte-pugh score for severity- Encephalopathy, bilirubin, ascites, albumin, PT
MELD - Gives a % 3 month mortality- used every 6months for patients with compensated cirrhosis
69
How might you diagnoses spontaneous bacterial peritonitis?
Ascitic diagnostic tap
Cell count: WCC > 500/cm3 ± Neutrophils >250/cm3
Albumin: serum ascitic albumin gradient = serum albumin - ascitic albumin g/L
HIGH SAAG = liver cause - portal hypertension
Low SAAG = malignancy, trauma, infection
70
What is fulminant hepatic failure?
A potentially reversible severe liver injury with the onset of hepatic encephalopathy within 8 weeks of the appearance of the first symptom with no history of pre-existing liver disease
71
What is the difference between hyperacute, acute and sub-acute liver failure?
Hyperacute is Hepatic encephalopathy within 7 days of jaundice
Acute is HE within 8-28 days of jaundice
Sub acute is HE within 29-84 days of jaundice
72
What is the definition of acute liver failure and the criteria?
Potentially reversible severe liver injury, with an onset of HE within 8 weeks of the first symptoms in the absence of pre-exisitng liver disease.
INR >/= 1.5
Neurocognitive disturbance with any degree of hepatic encephalopathy
No pre-exisitng liver disease
Disease course = 26 weeks
73
What are the grades of hepatic encephalopathy?
Grade 1 - Drowsy but coherent: mood changes
Grade 2 - Drowsy, confused at times, inappropriate behaviour
Grade 3 - Very drowsy, stuporous but rousable, or restless and screaming
Grade 4 - Comatose - barely rousable
74
What do you give in a paracetamol overdose?
N-acetylcysteine
75
In acute liver failure, what treatment can you give for a prolonged PT?
IV vitamin K 10mg ONCE
76
In acute liver failure what could you give for cerebral oedema?
Mannitol 100ml 20%
| ICP monitoring
77
What treatment could you give if Wilsons disease was causing acute liver failure?
Penicillamine and IV vit E
78
Where might you get Hepatitis A and what is the management?
Travel related. Faecal oral route. Shed via biliary tree into gut. Usually always acute.
Can cause Acute liver failure.
Tx - Maintain hydration, avoid alcohol, self-limiting
Vaccine - inactivated virus
79
What is special about Hepatitis E?
Can cause neurological symptoms - Guillain barre syndrome, ataxia, myopathy
Tx - Ribavirin
80
Hepatitis B is diagnosed if sAg or DNA is detectable for it, what does HBV DNA mean/indicate?
Viral load count
81
How would you manage chronic Hep B infection (HBaAg or HBV DNA detected >6months)
Suppress viral replication and prevent further liver damage
Immune-modulatory - Interferon
Suppress viral replication - Tenofovir or Entecavir
82
What is special about Hepatitis D?
Requires Hepatitis B to survive and replicate
| Tx - Peg IFN
83
How can you distinguish Hep C?
Extra-hepatic manifestation such as fatigue, depression, diabetes, neuropathy, CVD, cancer
Tx- Direct acting antivirals PO 8-12wks (Ribavirin + Peg IFN)
84
What is IBS?
A mixed group of abdominal symptoms in which no organic cause can be found.
85
What is the diagnostic criteria for IBS?
Abdominal pain/ discomfort
Relieved by defecation or associated with an altered bowel frequency to altered stool
AND >/=2 of:
Urgency, abdominal bloating, incomplete evacuation, mucous PR, worsening of Sx after food
86
What is an adenomatous polyp?
A true neoplastic polyp formed by excessive growth of the colorectal epithelium
87
What is Familial adenomatous polyposis?
AD mutation in APC gene on chromosome 5
| Characterised by thousands of adenomatous polyps in the colorectum and increased formation in the stomach and duodenum.
88
What is hereditary non-polyposis colorectal cancer?
AD mutation in the mismatch repair gene (MMR) which predisposes to increased genetic defects to acquire in the polyps.
Increased risk of other cancers: Ovarian, stomach, hepatobiliary, brain, upper urinary tract
89
What is feacal calprotectin?
Calcium binding protein, predominantly derived from neutrophils
90
What is Crohns disease?
A chronic transmural granulomatous inflammatory disease affecting the entire gut, from mouth to anus.
Most common site - ileum and colon
91
What can help distinguish between crohns and UC?
Anti-saccharomyces cerevisae antibodies (ASCA)
92
What biological agents can be used in Crohns?
Anti-TNF - adalimumab, Infliximab
Anti-integrins - alpha4beta7 Vedolizumab
Anti-IL12/23 - Ustekinumab
93
What score can be used in the endoscopic findings of Crohns?
Rutgeerts
94
What is first line in Crohns disease?
Steroids - PO 20-40mg Prednisolone or IV hydrocortisone
| 2nd line - PO 2-2.5mg/kg Azathioprine or 6-mercaptopurine
95
What drugs are used in the remission of Crohns?
Azathioprine or 6-mercaptopurine
| 2nd line - biologics
96
What is the most common type of colorectal cancer?
Adenocarcinoma of rectum
| Usually on the LEFT
97
What staging is used in colorectal carcinoma?
```
Dukes staging
A- confined to the mucosa
B - infiltrated the muscular wall
C- local lymph node spread
D - distant mets
```
98
What is the most common site of diverticulitis?
Sigmoid colon
| LIF pain
99
What might AF and abdominal pain indicate?
Mesenteric ischaemia
100
What is the most common cause of SBO and LBO?
SBO - adhesions
| LBO - cancer
101
What is rigler's triad?
For gall stone ileus, in the remnant of the vitelline intestinal duct, 20cm from terminal ileum
Pneumobilia
Radiolucent gall stones
SBO
102
What is the triad seen in serotonin syndrome?
```
Autonomic instability (HTN, excessive sweating, mydriasis, hyperthermia, tachycardia)
Mental status change (anxiety, confusion, coma)
Neuromuscular features (clonus, hypertonicity, hyperreflexia)
```
103
Kings criteria is used in paracetoamol overdose to determine the need for a liver transplant. Explain the criteria.
pH < 7.3 or lactate > 3mmol/L following resus OR
| AKI/ Creatinine >300 + INR > 6.5/ PT>100s + grade 3/4 encephalopathy
104
Describe paracetamol metabolism in a paracetamol overdose.
In an overdose the enzymes used to metabolism paracetamol become saturated and so it is metabolised a different way and becomes NAPQI.
NAPQI is a toxic metabolite but is inactivated by glutathione. When Glutathione becomes saturated NAPQI is free in its toxic form and causes necrosis.
N-acetyl-cycteine works to restore glutathione
105
What could you give in a methanol or ethylene glycol overdose?
Ethanol
| Competitively blocks the formation of toxic metabolites by having a higher affinity for alcohol dehydrogenase
106
What could you give in a beta blocker overdose?
High dose Insulin therapy
107
What could you give in a calcium channel blockers overdose?
6g IV Calcium gluconate over 5-10min or in severe overdose high dose insulin therapy
108
What could you give in a benzodiazepine overdose?
Flumazenil
109
What could you give in a TCA overdose?
Hyperosmolar sodium bicardonate
(used in drugs that impair fast acting Na channels)
for any drug ingestion <1 hr - activated charcoal
110
What could you give in a digoxin overdose?
Digi bind
111
What is Riglers sign?
Double wall sign - Due to there being intraluminal and extraluminal free gas
112
What signs might present on AXR in a patient with UC?
Thumb printing in an acute presentation due to mucosal thickening and oedema of the haustra
Lead pipe colon in chronic presentation, loss of normal haustra
Toxic megacolon, life threatening dilation without obstruction and systemic response
113
What is a key finding that would indicate an intra-abdominal abscess?
Swinging fever** - usually over 38.5 degrees occurring twice a day, followed by tachycardia
114
What are some causes of chronic gastritis?
ABC
Autoimmune - Pernicious anaemia
Bacteria - H.pylori - High IL-8 - pangastritis or low IL-8-antra-predominant gastritis
Chemical - NSAIDs, bile reflux, ethanol, oral iron
115
Adenocarcinoma is the most common type of gastric carcinoma, what are the classifications of gastric cancer?
Diffuse - associated with GORD, affects cardia
Intestinal - associated with H.pyloir. Affects antrum and body. Associated with Pangastritis as there are high levels of IL-8, hypochloridia, atrophic gastritis, intestinal metaplasia, dysplasia and then cancer
116
What is cholangitis?
Infection of the biliary tree (CBD), due to outflow obstruction and infection.
(stone, stricture, post-ERCP, cholangiocarcinoma)
Ecoli, enterococcus, klebsiella
117
What does it mean for acute pancreatitis to be mild moderate or severe?
Mild - no organ failure to local or systemic complciations
Moderate - organ failure lasting less than 48 hours ± local or systemic complications without persistent organ failure
Severe - single or multi organ failure
118
What triad is seen in wernickes encephalopathy?
Opthalmoplegia, ataxia, cognitive impairment
119
What are some causes of cirrhosis?
Drugs - methotrexate, amiodarone
Alcohol - Alcoholic hepatitis, alcoholic fatty liver
Metabolic - Non-alcoholic fatty lover disease or Non-alcoholic steatohepatits
Inherited - HH, Wilson's, alpha1 antitrypsin def
AI - AI hepatitis, PBC, primary sclerosing cholangitis
Infection - Hep B or C
120
Before you do an ascitic tap what do you need to know and where do you perform the tap?
INR < 1.5, Platelets > 50
3-5cm under umbilicus or 5cm superiomedially from ASIS
121
Explain how you would interpret serum albumin ascites gradient?
If its hight, ie more serum albumin - Traunduate - due to portal hypertension - cirrhosis, hepatic failure, portal vein thrombosis, alcoholic hepatitis
If low, ie more ascitic albumin - exudate - infection or malignancy - TB, malignancy, pancreatitis, nephrotic syndrome, bowel obstruction
122
What is primary sclerosing cholangitis?
AI liver disease. Causes Cholestasis due to progressive fibrosis of the intra and extra hepatic ducts.
Can eventually cause cirrhosis or cholangiocarcinoma
LFTs show obstructive picture with raised ALP
May be ANCA +ve
Associated with IBD - UC
123
How might you differentiate PBC and PSC?
PBC - Interlobular bile ducts destroyed. 10F>M, 50-60y, anti-mitochondrial antibodies
PSC - Intra and extra hepatic ducts, 2M>F, 30-40y, ANCA, IBD
124
List some anatomical features of crohns and UC.
UC - Loss of haustra, perudopolyps
Crohns - Fat wrapping, cobble stoning, thick walls, strictures (can cause obstruction in a virgin abdomen), ulcers, fissures
125
What are some clinical signs of cirrhosis ?
Caput medusa, spider naevi, palmer erythema, SBP, splenomegaly, bruising, gynaecosmatsia, malnourished, asterixis
126
What is decompensated liver cirrhosis?
Acute deterioration in liver function in patients with cirrhosis.
Jaundice, ascites, hepatic encephalopathy, sepsis, renal impairment, GI bleeding
127
What are some precipitants of decompensation in cirrhosis?
GI bleeding, constipation, dehydration, infection/sepsis, Alcoholic hepatitis, HCC, acute portal vein thrombosis, drugs (alcohol, NSAIDs, opiates), ischaemic liver injury
Complete BASL bundle within 6 hours of admission
128
In the BASL bundle for decompensated cirrhosis what might you give if there is a Hx of alcohol excess?
IV Pabinex
Fixed dose and symptoms triggered tx
Use LORAZEPAM instead of diazepam - slower onset but rapid elimination of metabolites not impaired in liver disease
129
How would you manage a patient if the ascitic tap had >250cells/mm3 PMN?
IV antibiotics according to protocol
IV amoxicillin + Temocillin
or if penicillin allergic - IV Ciprofloxacin + Vancomycin
IV albumin - 100ml 20% albumin
Long term prophylaxis if indicated - Co-trimoxazole, Rifaxamin***
130
In decompensated cirrhosis they use the BASL bundle, what are the 7 areas looked at?
1. Investigations
2. Alcohol - Pabrinex, lorazepam
3. Infections - SBP? albumin and Abs
4. AKI - fluid resus, stop nephrtoxins
5. GI bleeding - terlipressin + Abx, IV Vit K? FF? plts? transfusion?
6. Encephalopathy - Lactulose
7. Other - VTE prophylaxis
131
What drug can be given in patients who have had an episode of HE to prolong remission and reduce hospital admission?
Rifaximin
| Decreases production and absorption of ammonia
132
What are the grades of HE?
```
Cerebral oedema
Spikes in HTN
Deconjugated eye movements
Papilloedema
If not treated -- Decerebrate posturing and brainstem coning
```
133
What is the criteria for a liver transplant in acute liver failure?
Paracetamol OD with pH <7.3
Grade 3/4 encephalopathy AND PT > 100s
Or ALL 3 of
PT > 100s, Cr >300microM, grase 3-4 HE
134
What drugs can cause hypotension with bradycardia syndrome?
BB, Ca channels, digoxin
135
What test would you do in a 18year old male with suspected appendicitis?
CT abdo/pelvis - are the suitable for conservative management - IV antibiotics
Laparoscopy
(US would not move you forward - in females as looking at gynae pathology too)
