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Myhairis differentnow sorryguys TCD 15 + 16: Jaundice ? By Zakariya Mouyer, Omar ZarZar, Mawran TahowowownSignupform→receiveemailwithfeedbackform→filloutfeedbackwithin24hrs→receiveslides+recording@scrubbedup_ *Disclaimer* The content of this presentation was created by med students for med students. This session isn’t intended to replace any formal education provided by the uni of mani, so make sure to review all the cases on 1Med and read your ILOs and attend at least 40 hours/week of clinical experience ;)Admin Stuff - Youknowthedrill - Anyadminstuffpleaseemailscrubbed-up@outlook.comrather thanmessagingoneofuspersonally:)) - Stopcomplainingabouttheheatingomlenjoyitwe’relegitina costoflivingcrisisrntellmeurrichwithouttellingmeurrichSo what is this teaching exactly? Covers the main pathologies mentioned in each week’s TCD Progress Test, CCA/OSCE, DDx, top notch medics basically NOT HERE TO HOLD YOUR HAND THROUGH THE 1MED CASES Person/ aka ‘a wild zik’ SUCCINCT, HIGH YIELD, SHARP and ACCO M KEYWORD IS نﺎﺳﺣإ E N / E "Excellence is not a gift, but a skill that H takes practice, we do not act 'rightly' O D because we are excellent, in fact we achieve excellence by acting rightly" Greek Donny - (Plate-pusher Plato) Ends/Desired Goal Contents ❏ Alcoholic Hepatitis - ❏ Cirrhosis - ❏ Encephalopathy - ❏ Viral Hepatitis - ❏ Liver Failure - ❏ Intoxication and Poisoning ❏ Ascites + Jaundice - ❏ Haemochromatosis ❏ Pancreatic Cancer?Liver Function Tests - R(rapid review)LFTs (why and what?) WhydowedoLFTs?Discuss ➔ Clotting(prothrombintime,INR) ➔ Albumin ◆ Liverdisease=↓albuminproduction ◆ Inflammation=↓albuminproduction(notusefulinacute..why?) ◆ EnteropathiesorNephroticSyndr↑↑loss=↓albumin ➔ Enzymes(3xUL) ◆ AST,ALT,ALP ● ALT,AST>>ALP=HEPATOCELLULAR ● ALT,AST<<ALP=BILIARY/OBSTRUCTIVE ◆ Gamma-GT=biliarytreeirritation,risesafteralcohol ➔ Bilirubinaround50µM/L=jaundice ↑ALP+↑GGT-thinkbiliarydisease ↑ALP+normalGGT-thinkbonedisease LFT interp - detail tings ➔ ALT/ALP ◆ ↑↑10xALT:ALP-->hepatocellularinjury ◆ ↑↑3xALP:ALT-->cholestasis ◆ Both-->mixedpicture LFT interp - detail tings ➔ ALP/GGT ◆ ↑↑ ALP + ↑↑ GGT --> cholestasis ◆ ↑↑ ALP alone --> bone disease (bone cancer/↑↑ PTH/osteomalacia/Paget's) ◆ ↑↑ GGT alone → alcohol/enzyme-inducing drugs LFT interp - detail tings ➔ ALT/AST ◆ ALT>AST-->non-alcoholicliverdisease(mainly viral) ◆ AST>ALT-->alcoholicliverdisease/cirrhosis ● AST=ASipofTequila ◆ AST:ALT>2-->alcoholicliverdisease ◆ ALT>500-->notALD(evenif...) ◆ ALT>1000-->viralhepatitis ◆ ALT>10,000-->paracetamolOD LFT interp - detail tings ➔ Syntheticfunction ◆ ↓↓Albumin→ ● Hepatocellularinjury(chronic-half-life=20days) ● Nephroticsyndrome/protein-losingenteropathy ● Inflammation(negativeacute-phasereactant). ◆ ↑↑PT→ ● Hepatocellularinjury(acute/chronic) ● ↓↓VitaminKPreHepatic NormalUrine NormalStools IntraHepatic VariableUrine VariableStools PostHepatic DarkUrine PaleStoolsJaundice RJaundice (icterus) ➔ Yellowpigmentationoftheskincausedby ↑bilirubininblood ➔ UnconjugatedHyperbilirubinemia - ○ Notfromliverorbiliarytree ➔ ConjugatedHyperbilirubinemia - ○ Causedbyliver&biliarydisorders Bilirubin LFTs summary ➔ Bilirubin ◆ ↑↑UBr→ ● Pre-hepatic(haemolysis) ● Intra-hepatic(↓↓uptake/conjugation) ◆ ↑↑CBr→ ● Intra-hepatic(hepatocellularinjury/↓↓excretion ● Post-hepatic(cholestasis)Pre-Hepatic Jaundice ➔ UnconjugatedBilirubin(UCB) hasnoeffectonurinebecauseUCBiswater insoluble ➔ Overproduction- Haemolysis(Malaria+Others),IneffectiveErythropoiesis (haemolyticanemia,G6PD..case11),RBCabnormalities(sicklecell,hypersplenism) ➔ ImpairedHepaticUptake-Drugs(egparacetamol,rifampicin),Ischaemic Hepatitis ➔ ImpairedConjugation-GilbertsSyndrome,Crigler-NajjarSyndrome ➔ Yellowingofskin+eyesinnewbornbabies ➔ NeonatalJaundice-Combinationofabove ➔ Newbornshavehighconc.ofRBCandnotafullydevelopedliver--->↑UBinblood ➔ UBcancrossBBBandcauseneurologicaldysfunction(encephalopathy/kernicterus DANGER) ➔ Treatedwithphototherapy(breaksUBdownsoconjugatesitwithoutliverandthen excreted)Intra-Hepatic Jaundice (Hepatocellular) Whataresomeintra-hepatic causesofjaundice?Discuss ➔ Causedbydysfunctionofhepatocytes (cancausemixedpictureof ↑UCB+↑CB) ➔ DamagetothehepatocytesreleaseALT(reasonfor↑ALTinLFTs) ➔ Causes ➔ Haemochromatosis-↑ironinblood ➔ Leadstomanydifferentsymptoms ◆ AlcoholicHepatitis (tiredness,bronzeskin, ◆ Cirrhosis ➔ Liverbiopsyshows“perl’sstains”(iron ◆ ViralHepatitis deposits) ◆ NAFLD ◆ DrugInduced(paracetamol,statins,TBdrugs) ➔ Wilson’sDisease -↑copperinblood ◆ AutoimmuneLiverDisease depositsonliverandinCNS ◆ Haemochromatosis ➔ Causesliver/neuro/psychiatricproblems ◆ Wilson'sDisease ➔ Kayser-Fleischerringsincornea ➔ Treatwithcopperchelation(penicillamine) PainlessJaundicein<40y/o…thinkGilbert'sSyndrome “-chol-”prefixmeanstodowithbile/gallbladder Post-Hepatic Jaundice (Cholestatic or Obstructive) ➔ Causedbyblockageofbileflow→DamagetobileductreleaseALPandGGT (therefore↑↑ALPseeninLFTs) ➔ ConjugatedHyperbilirubinemiaismorecommoninclinicalpractiseand presentswithDARKURINE+/-PALESTOOLSandinseverecasesPRURITUS (fancywordforitching) symptomsseenin intra-hepaticjaundicetoo ➔ Causes (slidebefore) ◆ HeadofPancreasCancer(REDFLAG--->PAINLESSJAUNDICE!)ngcholangitis) ◆ CompressionofBileDucts(portahepatislymphnodeenlargement) ◆ PrimarySclerosingCholangitis ◆ Cholangiocarcinoma(REDFLAG--->PAINLESSJAUNDICE!+/-UCPMHx)Hepatitis - Z 11.40 Whyaresomecausesofacute hepatitis?Discuss Hepatitis – Acute Liver Inflammation ➔ Hepatitisisinflammationintheliver. ◆ Variesfromchroniclowlevelinflammationtoacute/severeinflammation---> necrosisandliverfailure ➔ Symptoms-Abdopain,fatigue,pruritus,muscle/jointaches,N&V,jaundice, hepatomegaly,?fever;?asymptomatic ➔ IncreasedAST,ALTmorethanALP;increasedbilirubin ➔ Causes ◆ Viral(A,B,C,D,E,EBV,CMV) Antidote? N-Acetylcysteine ◆ Alcoholic,NAFLD ◆ Autoimmunehepatitis,primarysclerosingcholangitis,primarybiliarycholangitis ◆ Druginduced(flucloxacillin,anti-epileptics,paracetamol,methotrexate,rifampicin) ◆ Extra-hepaticobstruction(headofpancreascancer,gallstones) ➔ Primary Biliary Cholangitis - autoimmune attack of small bile ducts in liver ➔ Leads to Cholestasis (blockage of bile ducts) ➔ Back up pressure by obstruction leads to fibrosis, cirrhosis and liver failure. ↑ Bile Acid/Bilirubin/Cholesterol absorption in blood ➔ Bloods - ↑ALP, ↑ESR, ↑IgM, +ve Anti-mitochondrial antibodies, +ve Antinuclear antibodies (in ~ 35% of cases) ➔ Treatment - Ursodeoxycholic acid (↓ absorption of cholesterol by intestine), Colestyramine (bile acid sequestrate - binds to bile acids to prevent absorption), consider liver transplant and/or immunosuppression in some casesCauses of Hepatomegaly - Factos 2Is,2Bs,2Cs - Infx-Hepatitis,EBV,malaria - Infiltration-Sarcoid/Amyloid - Biliary-PSC/PBC - Blood-HaemMaligs - Congestion-Budd-Chiari,RHF,TR - Cancer-HCC(rip)/mets Viral Hepatitis - straight hardcore factos ➔ HepBmostcommoninworld ➔ HepCmostcommoninUK ➔ HepB+CcauseHCC ➔ HepBisDNA ➔ HepACDEareRNA ➔ VaccineavailableonlyforHepA+B ➔ HepDcanonlyinfectif→HepB co/super-infection(clingymuchamirite?)Hep B ➔ Transmit? ◆ Blood,bodilyfluids,‘intimaterelations’/sexworkers,IVDU,preggobutnoBF ➔ S/S? ◆ Fever,Jaunds,ALT/ASTbig ➔ Complications? ◆ HCC,LiverFailure,PAN ➔ Rx? ◆ Vaccinations-like3ofthem+testantibodylevels ◆ Acutely-pegylatedIFNalpha-oranydrugthatendsin-virHBsAg=SurfaceAntigen-firsttoappear→producesAnti-HBs Anti-HBs/HBsAb=SurfaceAntibody→vaccy/previnfx Anti-HBc/HBcAb=CoreAntibody→acuteinfx/previnfx IgM=Acuteinfx (acute=short m=maria mariaisshort) IgG=ChronicinfxHep C ➔ Transmit? ◆ Blood,bodilyfluids,‘intimaterelations’/sexworkers,IVDU,preggobutnoBF ➔ S/S? ◆ Fever,arthlagia,Jaunds,ALT/ASTbig→shorterincubationperiod ➔ Complications? ◆ HCC,MAJORCIRRHOSIS,Rheumstuff(sjogren’sandarthritis) ➔ Ix? ◆ HCVRNAPCR→activeinfx ◆ Anti-HCVantibody→previousexposure ➔ Rx? ◆ Vaccinations-NONEAVAILABLE ◆ ProteaseinhibitorsandRibavirinHep A ➔ Transmit? ◆ Faeco-oral→shellfish/pork(oinkoink)→travellerstoSEAsia/Afrique ➔ S/S? ◆ Self-limiting→-Flu-likeprodrome,RUQpain,Tenderhepatomegaly,Jaundice,CholestaticLFT ➔ Complications? ◆ Rare ➔ Rx? ◆ Vaccinations-towhoriskgroupsonlyAutoimmune Hepatitis ➔ Transmit? ◆ Autoimmune→raisedIgG ■ Kids ● anti-LKM1 ■ Post/Peri-menopause ● ANA/ASMA ➔ S/S? ◆ AcuteHeppresentation/ChronicLiverDisease ➔ Dx? ◆ Liverbiopsy-->inflammationextendingbeyondlimitingplate"piecemealnecrosis" ➔ Rx? ◆ Steds+Azathioprine ◆ LiverTransplantHaemochromatosis ➔ ARGeneticironstoragedisorder ◆ highserumferritinandtransferrinandLOWTIBC ➔ Causes: ◆ T1DM,cirrhosis,pituitaryirondeposits/DI,cardiomyopathy,HCC,hypothyroidism, chondrocalcinosis ➔ Ix ◆ Ironstudies(↑↑ferritin + ↓↓TIBC+↑↑transferrinsaturation) ➔ Rx ◆ Venesectionnew diabetes + liver fibrosis +/- joint pain +/- ammenrhoea (if female) - Dx? ➔ Lolgotcha ➔ Heheheehee ➔ HeredHaemochromatosisisisisWilson’s ➔ ARabsorptionexcretiondiseaseofCopper ➔ Presentsat10-25 ◆ Youngermorehepatic ◆ OldermoreEncephalopathic ➔ S/S ◆ Hepatitis,Cirrhosis ◆ Ba■alBehavioural/psychiatricproblems. ■ Asterixis. ■ Chorea. ■ Dementia. ■ Parkinsonism. ◆ Kayser-Fleischerrings. ◆ Bluenails. ◆ Haemolysis. ◆ Renaltubularacidosis ➔ Ix-obviousissuehereissss……? ◆ ↓↓Serumcaeruloplasmin-coppertransportthing-madeinliver ◆ ↓↓Serumcopper(counter-intuitive,but95%ofplasmacopperiscarriedbyceruloplasmin). ◆ ↑↑24-hoururinarycopper ➔ Rx-copperchelationwithaCopperPENny→PENicillamine/trientine Niché Liver Diseases (progress test stuff for the neeks/zaks) ➔Alpha-1AntitrypsinDeficiency:proteaseexcessattackingliver(after50)andlung(after 30);testforlowserumalpha-1antitrypsin;stopsmoking,organtransplant,monitorHCC ➔PrimaryBiliaryCirrhosis:autoimmuneobstructionofliver’sintralobarducts(Canalsof Hering)->fibrosis,cirrhosis;xanthoma,jaundice,palestools;middleagedwomenw.other autoimmunediseasesorrheumatoidconditions;AMA,ANA,biopsy ➔PrimarySclerosingCholangitis:strictureofintra/extrahepaticducts,bileobstruction-> hepatitis,fibrosis,cirrhosis;riskofcholangiocarcinoma;?auto-immune(UC/pANCA), middle-agedmales/UC/FH;MRCP;transplant ➔LiverCancer:HCC(AFP;resection,transplant)orcholangiocarcinoma(CA19-9;resection)Jaundice History ➔ PC/HoPC ◆ Wheredidyouseetheyellowing (eyes/face/trunk?) ◆ Whendidyou(orsomeoneelse)firstnotice? (eyes/face/trunk?) ◆ Anythingmakingitworse?(foods?) ◆ GASTROREVIEW!N/V?SwallowingDifficulties/Indigestion/HeartBurn?AbdoPain/Swelling? Jaundice?Itching?darkurine?palestools?changeinbowelhabits/bloodormucus?OTHER: fever?rash?confusion?weightloss?nightsweats?andbloodloss ➔ PMH-Anyconditionsyousufferfrom?Haveyoubeenjaundicedbefore? Recentbloodtransfusion?Anysurgeries?Allergies? ➔ FHx-Anydiseasesrunninginthefamily?Anyauto-immuneconditions? ➔ DH-Medications? ➔ SH-Smoking?Alcohol(CutdownAnnoyedGuiltEye-opener)?Drug use?Unprotectedsex?TravelHistory?IVDU/occupationalneedlestick? Tatoos?Quick Quiz ➔ Namethethreecategoriesofjaundice ➔ ↑ALP+normalGGT…whatyouthinking? ➔ Whatarethe3mainsymptomsofAscendingCholangitis?bonuspoints…nameoftriad? ➔ Whydoyougetpalestoolsanddarkurineinobstructivejaundice? ➔ Howdoyoutreatneonataljaundice? ➔ Patientpresentswith3/wofpainlessjaundice…whichtwoconditionsdoyouneedtoinvestigatefor? ➔ WhatLFTresultswouldyouexpectforacutehepatitis? ➔ Name3 differenttypesofhepatitiscausesOverdose and Poisoning - legit progress flipping gold adders 12.00Imma do this like a quiz icl ➔Paracetamol ◆ 1hour-activecharcoal ◆ >1hour-NAC ◆ SevereaccordingtoKCL→livertransplant ➔ Opiates ◆ Naloxone ➔ Benzos ◆ Flumazenil ➔ TCA-amitrippy ◆ NaHCO3 ➔ Lithium ◆ Fluidsandifsevere-dialysisImma do this like a quiz icl ➔Salicylate ◆ Aspirin-IVHCO3- ◆ Dialysis ➔ Methanol ◆ Fomepizole/Alcohol ◆ Dialysis ➔ Antifreeze/EthyleneGlycol ◆ Fomepizole/ethanol ◆ Dialysis ➔ OrganophosphateInsecticide-SLUDB ◆ Atropine ➔ Lead ◆ abdopain+motorneuropathy+depression+↑↑deltaaminolaevulinicacid+ porphobilinogenImma do this like a quiz icl ➔Warfarin ◆ DependsonINRandbleedstatus-vitKandPTC ➔ Heparin ◆ ProtamineSulphate ➔ BetaBlockers ◆ AtropinethenGlucagon ➔ Antimuscarinics-Atropine ◆ Phyostigimine-moa? ➔ Digoxin ◆ Digibind ➔ Iron ◆ Desferrioxamineunconscious diaphoresis, urinary and faecal incontinence, bradycardia and miosis along with muscle fasciculation male presents to DGH ➔Howtotreat? ORGANOPHOSPHATEINSECTICIDEHEHEHEThe Alcoholic Liver 12.00 Alcoholic Liver Disease Progression ➔ Alcohol-relatedfattyliver(reverses2weeks) ➔ Alcoholichepatitis(usuallyreversible) PortalHTNleads ➔ Cirrhosis(irreversible)-Endstageliverdisease+fibrosistoblackflowanda portosystemic nodules shunt→SAVE ◆ constantactivationofstellatecells->fibrotictissuebuildup->compressionof S-Splenomegaly centralveins/sinusoids A-Ascites ■ PORTALHYPERTENSION V-Varices E-Encephalopathy ◆ CompensatedCirrhosis=nomajorcomplications…DecompensatedCirrhosis=major complications ◆ CIRRHOSISINDUCEDPORTALHTNCAUSES SA VE???? To confirm spider naevi you can press on them and see if they blanch/disappear <3 Jaundice Hepatomegaly Spider Naevi Palmar Erythema Gynecomastia Caput Medusae Whoever can name all the DISCO Ascites drugs without googling can be my bff xCirrhosis ➔ Commoncausesapartfromalcoholicliverdisease ◆ NAFLD ◆ HepatitisBandC Potential Progress Test Content ➔ Uncommon ◆ Autoimmunehepatitis,primarybiliarycirrhosis,haemochromatosis,Wilson’sdisease,Alpha-1 antitrypsindeficiency,cysticfibrosis,drugse.g.amiodarone,methotrexate,sodiumvalproate ◆ KnowabitabouteachforMCQ’s! ➔ Child-Pughscoreforcirrhosistoscoreseveritybasedonbilirubin, albumin,INR,ascites,encephalopathy;prognostic ➔ MELD-Nascoreforestimated3-monthmortalityandreferralforliver transplantCirrhosis Investigations & Management ➔ Bloods ◆ ↑MCV(why?),↑AST&ALT,↑gamma-GT,↓albumin,↑prothrombintime(why?),U&Ederanged (↓Na+),hepatorenalsyndrome,ELF,alpha-fetoprotein(why?) ◆ Thrombocytopaenia-<150-mostsensitiveandspecificlabfindingfordiagnosisoflivercirrhosis ➔ USS&FibroScantocheckechogenicityandelasticityofliver(?cirrhosis), bloodvessels(corkscrewappearance),ascites,splenomegaly, ➔ CT/MRI ◆ Fattyinfiltration,HCC,hepatosplenomegaly,abnormalbloodvesselchanges,ascites ➔ Liverbiopsy ◆ Alcohol-relatedhepatitisorcirrhosis;NICErecommendsifconsideringsteroids ➔ Treatment(ifcausedbyalcohol): - Alcoholcessationanddetoxication - nutritionalsupport(thiamine,highprotein) - ?steroids(short-termbenefit) - treatcomplicationsofcirrhosis - ?livertransplant(3-monthabstinence)Cirrhosis General Management ➔ USSandAFPevery6monthsforHCC ➔ Endoscopyevery3yearsifnoknownvarices ➔ High-protein,lowsodiumdiet ➔ MELDscoreevery6months ➔ Considerlivertransplant ➔ Managecomplications ➔ Preventdecompensation:(acuteworsening)e.g.duetoinfection,alcoholbinge,GIbleed,hypoglycemiaCirrhosis Complications ➔ Malnutrition ➔ PortalHTN,varicealbleeding ➔ Ascites(isittransudativeor exudative?)andspontaneousbacterial peritonitis(mostcommonbacteria?) ➔ Hepatorenalsyndrome ➔ Hepaticencephalopathy(treatment?) ➔ Alcoholicliverdiseasecomplications ◆ HCC(tumourmarker:AFP) ◆ Wernicke-Korsakoffsyndrome ◆ Pancreatitis ◆ CardiomyopathyCirrhosis Complications Treatment Potential Progress Test Content ➔ Malnutrition:Regularmeals,lowsodium,highproteinandcalorie,C2 avoidance ➔ Varices: ◆ Stable:Propranolol,elasticbandligation,transjugularintra-hepaticporotsystemicshunt(TIPSS) ◆ Unstable: ■ First:vasopressin(terlipressin)+IVAbx ■ Haemostasis(VitaminK,FFP)+urgentendoscopy(sclerosant,ligation) ■ Uncontrollable:Sengstaken-Blakemoretubetamponade ■ Allfail?-TIPSSorifrefractoryascites/Budd-Chiari ■ AlwaysgiveIVPPIfor72hours ➔ Ascites:spironolactone,lowNa+diet,paracentesis,Abxprophylaxis ➔ SBP:asciticculture,IVcephalosporin-cangiveprophylactically ➔ Encephalopathy: lactulose,Abx,nutritionalsupportHepatic Encephalopathy ➔ ComplicationofCirrhosis ◆ Portosystemicshunts+reducedliverfunction-->reducedtoxinremoval(especially ammonia). ◆ Thesetoxinstraveltobrainandleadtohepaticencephalopathy. ➔PrecipitatingFactors ◆ Constipation,Alcoholbinge,Post-TIPSS ➔ S/S ◆ -Confusion,Vomiting,Irritability,Decreasedconsciousness,Seizures,Asterixis(liver flap). ➔ Rx ◆ Laxatives(e.g.lactulose)whichclearammoniafromgutbeforeit'sabsorbed. ◆ Secondaryprophylaxis→ antibiotics(e.g.rifaximin)-->reducedamountof ammonia-producingbacteriaingutAlcohol excess + DT ➔14units/wkover3+days,nomorethan5/day ➔Increasesriskofcanceresp.breast,mouth,throat ➔CAGEquestions ◆ Cutdown?Annoyed?Guilty?Eye-opener ➔Withdrawalsymptoms ◆ 6-12htremor,sweating,headache,craving,anxiety,palps ◆ 24-48h?seizures+visualTACTILEhallucinations/delusions ◆ 24-72h?deliriumtremens-fullblownnextslides Symptoms Delirium Tremens ● confusion ● agitation ● delusions ➔ Emergency,lifethreatening ● hallucinations ◆ ChronicalcoholexcesscausesGABAup-regulation, ● tremor ◆ NDMAdown-regulationtobalancealcoholeffects→workslikeabenzo ● tachycardia ◆ Whenalcoholisremoved,GABAunder-functions,glutamateover-functions ● HTN ● hyperthermia ◆ =>extremeexcitabilityofbrain ● ataxia ➔ Safewithdrawal ● arrhythmias ● seizure ◆ CIWA-ARtooltoguidemanagement(considermedicationforhigh-riski.e.≥8) ◆ Chlordiazepoxide(benzodiazepine)5-7daystitratethenwean ◆ GiveLorazepamifinliverfailure ◆ i.v.high-doseBvitamins(IVPabrinex)thenoralthiaminetopreventwhat? ● W/Ksyndromeand/orberiberi-deficiencyinwhichBvitamin? ● Sugar/Glucose-whatsthefusshere?Wernicke-Korsakoff Syndrome/beriberi ➔ Thiamine(B1)deficiency(poorlyabsorbedwithalcohol) ➔ Wernicke’s-CANOPN ◆ Confusion ◆ Oculomotordisturbance ◆ Ataxia ◆ NeedsB1treatmentandalcoholabstinenceotherwisehighmortalityrate ➔ Korsakoff’s ◆ Memoryimpairment(anterogradeandretrograde) ◆ Behaviouralchangese.g.confabulation,mood-swings ◆ Oftenirreversible ➔ Wet/DryBeriBeri ◆ dry=periphneuropathy,wet=high-outputdilatedcardiomyopathyQuick Quiz ➔ Namesomeoftheuniquelivercirrhosissigns ➔ WhataretheWernicke’ssymptomsandhowdowetreat? ➔ WhatdoweuseChild-PughScorefor? ➔ PainlessJaundicein<40y/o…whatshouldweinvestigatefor? ➔ ↑ALP+normalGGT…whatyouthinking? ➔ WhatdoesCAGEstandfor?Ascites + SBP - R 12.00 ● Symptoms ○ Diffusepain YUP ○ Fever ○ Increasingascites ➔ Asciticfluidisdrainedandtested(paracentesis) ● R/f=cirrhosis Intestinalbacteria→portalsystem→asciticfluid ◆ IfSBPissuspected,sendfoMCS: ■ Neutrophils>250/mm3 ■ Microscopyshowing>500whitecellspermm3 ■ Mostcommonpathogens→e.coliandklebsiellapneumoniae ● GiveprophylacticIVcephalosporins ➔ IfSBPisnotsuspectedwetestAFwithSAAG(tastesmidimojs) ◆ Serumascitesalbumingradient-SERUMALBUM:ASCITICALBUMINratio ◆ Transudate=LowproteincontentsoSAAG>1.1g/dL (hydrostaticpressure) ■ Cirrhosis-->portalhypertension. ■ Congestiveheartfailure/Budd-Chiari ■ Nephroticsyndrome ◆ Exudate=HighproteincontentsoSAAG<1.1g/dL (oncoticpressure) ■ Peritonealcancers. ■ Pancreatitis ■ PeritonealTBAscites Rx ↓↓Na+,diet,Fluidrestrict - Spironolactone+~loopdiuretics IfTenseascites-->paracentesis. - 5L-->20%albumin. GiveprophylacticAbxto(preventSBP). IfAsciticprotein≤15g→ - ciprofloxacin/norfloxacin. - 20%HAS Refractory/recurrent→ - TIPSS/livertransplant.Pancreatic Cancer - R 12.00 Courvoisier’sLaw Pancreatic Cancer RUQmass+mildpainlessjaundice→unlikelytobegallstones 80%=adenocarcinomasatheadofpancreas Signsandsymptoms ● Classically:Painlessobstructivejaundice +/-palpablegallbladder ● Common: Invx: ○ Epigastricpainthatradiatestoback ● LFTs-obstructivejaundice ○ Weightloss/anorexia ● CT-diagnosticandstaging ○ Hepatomegaly+malignantascites ● USS-dilatedducts+ruleout ● Rarepresentations: stonesinCBD ○ Lossofexocrinefunctions→ steatorrhoea/weightloss/↓VitADEK ○ Lossofendocrinefunction→DM ○ Atypicalbackpain ■ V(gastricoutflowobstruction) ■ TrousseausignofmalignancyManagement- Whipple it out ● Usuallypalliative→ERCPandstenting ● Surgery +adjuvanttherapy ● Removetheheadof thepancreas+ duodenum+ gallbladder/bileduct ● Attachwhat’sleftof pancreas/stomach/bi leduct→small Intestine ● SE:PUD/Dumping syndrome(rapid gastricemptying)EGO CHECK PROGRESS TEST PRACTICE. TODY WE END CAREERS - ESPECIALLY MINE RIP