Liver

Question 1

Uncontrollable bleeding even with endoscopy?

Answer 1

Blackmore tube

Question 1

Variceal hemorrhage management?

Answer 1

Terlipressin 5 days (even if suspected) + PPI antibiotics Ceftriaxone (these improve post endoscopic risk of bleed)
*Terlipressin stops bleeding but has no effect on mortality. antibiotics have an effect on mortality.

Question 2

Best prophylaxis for variceal bleeding/portal hypertensive gastropathy

Answer 2

Propranolol/carvedilol

Question 2

% of variceal GIB die, % rebleed within the first year,
band ligation % successful +Nbutyl cyanoacrylate for gastric varices, balloon %, medical therapy alone %, emergency shunting % mortality

Answer 2

*30% of variceal GIB die, 80% rebleed within the first year,
band ligation 90% successful +Nbutyl cyanoacrylate for gastric varices, balloon 80%, medical therapy alone 65%, emergency shunting 40% mortality

Question 3

Variceal surveillance in cirrhosis

Answer 3

No: Endoscopy 2-3y, Grade 1: 1year , Grade 2-3: propranolol

Question 3

unstable GIB due to ibuprofen got iv fluids, next

Answer 3

Urgent endoscopy ( Not IV PPI)

Question 4

specific for advanced portal HTN sign?

Answer 4

Caput medusae

Question 5

Ascites management?

Answer 5

Spironolactone

Question 5

SBP diagnosis and treatment?

Answer 5

E.coli, more than 250 PMN, treat with ciprofloxacin (oral/iv(, cefotaxime ceftriaxone, piperacillin/tazobactam + Albumin ( reduce mortality)

Question 6

Mixed SBP shows?

Answer 6

Perforation

Question 6

Prophylaxis SBP?

Answer 6

Cipro in ascites + protein below 15

Question 7

Portal HTN

Portal HTN definition?

Answer 7

more than 5mm in wedge hepatic vein pressure (represents sinusoids)

Question 8

Portal HTN leads to?

Answer 8

varices, ascites, splenomegaly, Hepatic encephalopathy

Question 9

Hepatic encephalopathy

Answer 9

Can be caused by variceal bleeding
Lactulose, rifaximin, phosphate enemas, aim for 3 times a day defecation

Question 10

Hepatic encephalopathy grading?

Answer 10

1: irritate 2: Confused, inappropriate behavior 3: Restless, incoherent 4: Coma

Question 11

TIPS most common complication

Answer 11

Hepatic encephalopathy, pulmonary HTN

Question 12

TIPS contraindication

Answer 12

Childpuff above 12, hepatic encephalopathy, RHF, Sepsis, unrelieved biliary obstruction

Question 13

TIPS indication

Answer 13

Refractory ascites, uncontrolled variceal bleeding, hepatic pleural effusion

Question 14

Platet trans

Answer 14

Below 50

Question 15

FFP

Answer 15

INR 1.5, Fibrinogen less than 1

Question 16

packed cell

Answer 16

Hb 7, 8 IHD

Question 17

Blatchford

Answer 17

GIB RISK assessment

Question 18

Decompensated Liver

Answer 18

Jaundice, hepatic encephalopathy, Asterixis, Constructional apraxia ( Draw a clock face )

Question 19

ALT above 1000

Answer 19

Drugs like labetalol, anesthesia, ischemia, viral hepatitis, autoimmune hepatitis

Question 20

Liver biopsy contraindication

Answer 20

PLT 50, INR 1.5, Severe coagulopathy, severe ascites, cholestasis , hydatid cyst, hemangioma, difficult body habitus, uncooperative,

Question 21

Alcoholic Steatosis VS Alcoholic hepatitis

Answer 21

Alcoholic Steatosis: AST/ALT >2, hyper echo liver fibroscan, high GGT Alcoholic hepatitis: AST/ALT >2, Raise IgA, Fever, jaundice, hepatomegaly, confusion, portal HTN, leukocytosis, thrombocytopenia, AST ALT reaches 500, treat with corton with maddrey score above 32, nutritional support, alternative pentoxifylline *minor iron overload may happen in alcoholics. *Even on biopsy it's hard to differentiate NASH and alcohol, the most reliable is the enzyme proportion.

Question 22

Suspected for chronic liver disease/cirrhosis

Answer 22

Transient elastography

Question 23

Paracetamol overdose

Answer 23

N acetylcysteine (glutathione substitute to conjugate with toxic metabolites, most effective if given within 8 hours of ingestion)-> Methionine toxicity has few initial symptoms, liver damage is max 2-3 days after ingestion, enzymes can reach 3000, amounts of 10gr, hypokalemia, severe: hypoglycemia

Question 24

liver transplant in paracetamol OD

Answer 24

PH 7.3 or ALL OF INR 6.5, CR 3, Grade 3 encephalopathy paracetamol mechanism: Conjugation to glucuronic acid

Question 25

Hepato renal syndrome

Answer 25

Renal vasoconstriction (raise Endothelin), poor prognosis, almost all patients have ascites and jaundice, Terlipressin -> TIPS -> Liver transplant

Question 26

Acute liver failure (non paracetamol) indication for transplant

Answer 26

INR above 6.5 or 3 of: Younger than 11, older than 40, Bili above 300, INR above 3,5, drug toxicity, time of jaundice to coma more than 7 days

Question 27

acute rejection Liver transplant

Answer 27

First month