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GI Flashcards

(49 cards)

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1
Q

Acute Liver Failure

A

INR > 1.5
Encephalopathy
No underlying liver disease
<26 weeks since initial insult

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2
Q

Drug induced liver injury (DILI)

A

Tylenol (most likely to cause ALF)
Anti-TB (INH)
Bactrim
Nitrofurantoin
Azoles
Phenytoin
Herbals and supplements are 10-20% cause of DILI ALF

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3
Q

Amanita toxicity

A

Mushroom hunter is the clue. Causes ALF and need to treat with charcoal if recent ingestion or penicillin G or silibinin (active ingredient in milk thistle)

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4
Q

Causes of transaminases >10,000

A

Tylenol
Hypoperfusion
Viral infection
Mushrooms

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5
Q

Entacavir

A

Treatment for acute HBV
positive HBsAg and anti-HBc IgM

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6
Q

Autoimmune hepatitis

A

Young pt with ulcerative colitis with positive ANA and anti-smooth muscle ab

Tx: steroids

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7
Q

Wilson’s disease

A

Eyeball rings, check ceruloplasmin and serum/urine copper

Tx: transplant and plasma exchange

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8
Q

Budd chiari

A

Hypercoagulable pt (malignancy) with ALF. Check RUQUS for clot in hepatic vein.

Tx: anticoagluation or TIPS

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9
Q

NAC

A

Used in all ALF but primarily Tylenol toxicity because it repletes glutathione

Improves transplant free survival if given early

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10
Q

Coagulopathy in ALF

A

INR predicts mortality but does not mean more hypocoagulable. Not prone to bleed

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11
Q

Renal Failure in ALF

A

60% develop, predicts mortality. Early CRRT > intermittent HD, especially for ammonia >200

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12
Q

Cerebral Edema in ALF

A

Of patients who don’t survive, brain death is direct cause of death in 34-50%

Monitor encephalopathy grading (1-4)
Grades 3-4 develop edema

Treat with mannitol. Lactulose does not improve survival (will not bring ammonia down as in chronic or acute on chronic liver failure). Can cause bowel dissection and aspiration

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13
Q

Intracranial hypertension treatment

A

Elevate HOB>30, minimize stimulation and treat fever

Vasopressors for CPP >50 and MAP>75
Mannitol: 0.5-1 g/kg for osm <320
Hypertonic saline with goal Na 1445-155
RRT if ammonia >200

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14
Q

When to refer for transplant eval

A

Coagulopathy: APAP INR>3 or non APAP >1.8, acidosis, hypoglycemia. Worsening encephalopathy and AKI

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15
Q

Alcoholic Hepatitis

A

Recent heavy EtOH
Rapid onset with jaundice <8 wks
+/- fever, large tender liver and ascites
AST>50
AST/ALT >1.5 and both >400
Bili >3

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16
Q

Alcoholic Hepatitis scoring

A

Discriminant function > 32
—> bilirubin and INR

MELD>20
—> creatinine, bilirubin, INR, Na

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17
Q

Steroids in alc hep

A

Transient 1 month survival benefit

Contraindications: infection, bleeding, acute pancreatitis, renal failure

Stop at day 7 if no improvement

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18
Q

Spontaneous Bacterial Peritonitis

A

Dx:
Absolute PMN > 250
Gram stain with no organisms

Tx:
3rd gen cephalosporin
FQ in PCN allergic
Give for 5 days
Albumin 1.5 g/kg day 0 and 1g/kg on day 3 —-> decreases mortality and renal failure

Avoid large volume paracentesis due to HDUS and stop nonselective BB

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19
Q

CLF Hepatic Encephalopathy

A

1st line: lactulose. Rigatoni
3rd line: neomycin, vancomycin, flagyl

Combination of two drugs is superior

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20
Q

CLF: Hyponatremia

Study These Flashcards
A

<135 is independent predictor of mortality

Treatment does not improve outcomes
Treat if <120 or with neurological sxs

Correct by <10 daily to avoid osmotic demyelination and free water restrict

Avoid hypertonic saline, salt tabs, tolvaptan unless severe symptoms

21
Q

HRS

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A

Cr: >1.5
Unchanged after albumin 1g/kg and 2 days off diuretics
In the absence of nephrotoxic drugs, shock, abnormal urine and renal US

22
Q

Type 1 HRS

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A

Creatinine doubles over 2 weeks or 50% reduced creatinine clearance.

Median Survival is <2 weeks

23
Q

Type 2 HRS

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A

Stable or slower progression over months with median survival of <6 months

Consider liver transplant

24
Q

Treatment of HRS

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A

1) Vasopressin or terlipressin, octreotide, levophed. These to increase MAP 10-15. 40-50% respond which increases short term survival. Levophed is better than vaso

2) albumin 1g/kg

Octreotide and midodrine are less effective

25
Resuscitation and transfusion
For actively bleeding patients correct INR if >1.5, transfuse platelets for <50 MTP: replete 1:1:1
26
Rockall risk stratification tool
Max 11. Determines severity of GIB (risk of rebleed and mortality) Requires endoscopic data
27
Glasgow Blatchford risk stratification tool
Max 23. Does not require endoscopic data. Stratified upper GIB patients who are low risk and candidates for outpatient tx prior to EGD
28
AIMS65 Score
Max score 5: no endoscopic data required. Determines risk of in hospital mortality from UGIB based on albumin, INR, AMS, SBP (blood pressure), and age
29
PPI Use in UGIB
Must neutralize acid to allow clot formation Decreases need for endoscopic intervention, less re-bleeding, decreased LOS H2 blockers do not decrease rate of rebleed
30
Pre-endoscopy tx
PPI Pro kinetics (erythromycin): shorter procedure time, decreased need for second look endoscopy Somatostatin/octreotide: theoretical benefit in bleeding ulcer disease
31
When to scope
Within 24 hrs (considered early): Decreased LOS, less need for surgical intervention, ?less recurrent bleeding and ?mortality benefit If scoped within 12h (very early): no difference in rate of rebleeding, need for surgery or mortality with ?decreased LOS
32
Management of re-bleeding
Initial endoscopy successful in majority of cases Second endoscopy should be attempted: surgery avoided in 73% cases with fewer complications this way. But notify IR and surgery
33
Variceal UGIB
In pts with cirrhosis assume it’s varices unless otherwise proven. Bleeds only stop spontaneously 50% of the time
34
Transfusion for variceal UGIB
Avoid over transfusion as it can cause rebound portal HTN and rebleeding
35
Variceal UGIB Tx
Start vasoactive meds: Octreotide: inhibits release of vasodilators which increases hemostasis and decreases rebleeding risk. Continue for 3-5d after hemostasis Vasopressin: constricts mesenteric arterioles and can lead to myocardial, cerebral, bowel and limb ischemia due to systemic vasoconstriction
36
Cirrhosis and UGIB
20% have infection on presentation and 50% developed while hospitalized Treat with prophylactic abx: decreases mortality, bacterial infxns, decrease rebleeding and LOS use FQ or ceftriaxone depending on antibiogram
37
Variceal bleeding
EGD within 12 hours if pt HDS Banding > sclerotherapy If refractory: repeat EGD, balloon tamponade, Porto-systemic shunt
38
Balloon tamponade
Temporizing measure for hemostasis. Patients must be intubated Blakemore: gastric and esophageal balloons with gastric suction port Minnesota tube: gastric and esophageal balloons with gastric and esophageal ports Need tension with 250-500g weight High risk of rebleed when deflated and esophageal rupture is a catastrophic complication
39
TIPS (transjugular intrahepatic portosystemic shunt)
For salvage therapy for persistent bleeding Contraindicated for heart failure, severe pulmonary hypertension, system infection, severe TR (procedure increases flow into right heart)
40
LGIB Management
Colonoscopy within 24 hours for high risk with purge prep (4-6L polyethylene glycol)
41
LGIB: for ongoing bleeding after colo or unable to perform colo
Radionuclide imaging: most sensitive. Catches bleeding at 0.1-0.5 ml/min but poor localization CT angio: 0.3-0.5 ml/min. Sens 85% and spec 92%. No therapeutic capability and must give IV contrast Angio: 0.5-1 ml/min. Widely variable success rates 25-70%. Accurate and therapeutic with selective embolization Surgery: rarely indicated but can be life safely. Blind colectomy carries high morbidity and mortality
42
C diff diagnosis
Diarrhea >3 loose stools in 24 he with clinical suspicion
43
C diff test types
1) enzyme immunosssay for glutamate dehydrogenase ag 2) enzyme immunoassay for toxins A and B (high false negative rate) 3) nucleic acid amplification (NAAT): detects genes specific toxigenic strains but does not test for active toxin production (detects carriers)
44
Risk factors for c diff
Antibiotics, age >65, hospitalization, severe illness, GI surgery, obesity, immunosupressuon, IBD
45
Severity of c diff
Non severe: wbc <15k and cr <1.5 Severe: wbc>15k or creatinine >1.5 Fulminant: hypotension, ileus or megacolon —> increase vanc dosing
46
Acute pancreatitis dx
Need 2/3: Abdominal pain c/w pancreatitis Amylase or lipase >3x ULN (amylase has shorter half life and not usually elevated in hypertoglyceridemia or alcohol) Findings on imaging
47
BISAP Score
Predicts mortality in acute pancreatitis: BUN, AMS, SIRS, age, pleural effusion
48
Fluid resuscitation in pancreatitis
Early aggressive fluids increases risk for fluid overload. Recommended to use goal directed therapy
49
Hypertriglyceridemia pancreatitis
If with concurrent lactic acidosis, hypocalcemia or multi organ failure: start plasmapheresis. Otherwise insulin gtt

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