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Showing posts with the label Hepatology

Treat the patient and not an Investigation report

Greetings of the day Dear Friends : Today story from Saudi Arabia one of the sweetest destination of my medical career so far. One day a 39 year old female Mrs Toaiba (name changed) presented to our clinic at King Fahad Medical City, Riyadh with a history of progressive painless jaundice of 2 weeks duration without any viral prodrome or offending drug intake. The lady was accompanied by her husband and two small kids. Anxiously her husband pulled out the referral report and showed to me. While reading it, my jaw fell in shock,as the report read , metastatic liver disease for further evaluation. The lady was very modest wearing a long Abaya and only her eyes were visible which were reflecting golden yellow color of Jaundice , the tell tale of her ailing Liver. The sweat family appeared very anxious as they had been told by the local doctors regarding the poor prognosis of the disease."Daktoor(Doctor)! Please do something to help her , I am worried " said her anxio…

Acute Liver Failure

Diagnosis :


AASLD guidelines :

Criteria for Diagnosis in Adults 
1. Jaundice < 26 weeks 
2.Coagulopathy (INR>1.5
3.Hepatic encephalopathy
4.No evidence of chronic liver disease.

Investigations

Hemogram, RFT, LFT, INR, ECGMonitoring of Blood sugars Arterial blood gasArterial ammonia  Blood culture Workup for Malaria /Typhoid/Leptospira/Rickettsial infection-if  suspicion of ALF mimickers Routine Viral hepatitis serology,sIgM anti HAV,HBsAg,anti-HBc ,IgM,anti HEV,anti HCV  If Wilson suspected: Ceruloplasmin levels, KFRing/Urinary copper  Brain imaging (CT/MRI) if there is a clinical suspicion Pregnancy test in females Severity assessment :

Poor clinical prognostic indicators  

Age >50 years Jaundice -encephalopathy interval >7 days Hepatic encephalopathy grade 3 & Higher Presence of cerebral oedema Creatinine >1.5mg/dl Presence of any 3 ----indicates Poor prognosis 
Management :
ICU admission  Supportive treatment  Infection: Surveillance  & Prompt treatment Coagulopathy : (Al…

Management of hepatic encephalopathy

Diagnosis ·Known or suspected CLD presenting with altered sensorium ·ALF ·No neurological cause on examination or imaging
Investigations         ·Neurological examination to rule out focal cause ·Hemogram RFT,LFT,INR, Sugar, ECG ·Arterial NH3 : >200ug/dl is associated with cerebral herniation , >75ug/dl is associated with Hepatic encephalopathy ·USG abdomen ·Brain imaging in relevant cases Severity assessment ·West Haven Grades Minimal HE : Normal examination , subtle changes in working /driving                        Abnormal visual perception , Psychometric  or number test   Grade !:Personality changes , attention deficits , depressed state or irritability Grade II: Change in sleep -wake cycle , lethargy , mood changes Flap+ Grade  III: Altered level of consciousness , disorientation , O/E Muscular rigidity, clonus, hyporeflexia  Grade IV: Stupor and coma  O/E : Oculocephalic reflex, unresponsiveness to noxious stimuli Management ·Grade I/II HE

Non variceal Upper GI bleed

Non variceal Upper GI bleed
Diagnosis

·History of Hemetemesis or Melena /Hematochezia ·H/O NSAIDS use /Anti coagulants/antiplatelets/steroids /Peptic ulcer Examination : Hemodynamic status , vitals Look for Vascular lesions on the skin Consider variceal if : Splenomegaly /ascites /Features of CLD    
Investigations

·Hemogram , RFT,LFT INR Sugar, ECG, X -ray chest   ·USG to rule out CLD ·Serology :HBSAg, anti HCV , HIV ·Plan UGI endoscopy   ·May need CT angiography   Severity assessment

·Endoscopic Findings.      Classification ·Active bleeding               Ia Brisk bleeding  1b Oozing ·Non bleeding visible vessel  IIa (visible vessel ) ·Adherent clot                     IIb ·Flat spot                              IIc ·Clean base                         III

Click to Calculate  Rockall score: Rockall scoring system
Management

Management of ascites in cirrhosis

Management of ascites  in cirrhosis Grading of ascites:

Grade I Detected by USG only , Grade II moderate ascites , Grade III gross ascites
Characteristics of ascites in CLD: wide gradient SAAG >1.1

Recommendations  1. A diagnostic paracentesis should be performed in all patients with new-onset grade 2 or 3 ascites, and in all patients hospitalized for worsening of ascites or any a complication of cirrhosis (Level A1).

2. Neutrophil count and culture of ascitic fluid (by inoculation into blood culture bottles at the bedside) should be performed to exclude bacterial peritonitis (Level A1).

3. It is important to measure ascitic total protein concentration since patients with an ascitic protein concentration of less than 15 g/L have an increased risk of developing spontaneous bacterial peritonitis (Level A1) and may benefit from antibiotic prophylaxis (Level A1).

4. Measurement of the serum–ascites albumin gradient may be useful when the diagnosis of cirrhosis is not clinically evident…

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis EASL Recommendations  1.A diagnostic paracentesis should be carried out in all patients with cirrhosis and ascites at hospital admission to rule out SBP. A diagnostic paracentesis should also, be performed in patients with gastrointestinal bleeding, shock, fever, or other signs of systemic inflammation, gastrointestinal symptoms, as well as in patients with worsening liver and/or renal function, and hepatic encephalopathy (Level A1). 
2. The diagnosis of SBP is based on neutrophil count in ascitic fluid of >250/mm3 as determined by microscopy (Level A1). 
3. Blood cultures should be performed in all patients with suspected SBP before starting antibiotic treatment (Level A1). 
4. Some patients may have an ascitic neutrophil count less than 250/mm3 but with a positive ascitic fluid culture. This condition is known as bacterascites. If the patient exhibits signs of systemic inflammation or infection, the patient should be treated with antibiotics (Le…