Friday, November 26, 2010

Surgery Revision

Morning revision: Hematemesis; Esophageal Varices, PUD

Esophageal varices:
accounts for 30% of UGIB
commonest etiology in msia: hepatitis B, Alcohol

Liver cirrhosis
--> increase in flow/portal vascular resistance
--> Portal hypertension
--> Development of portosystemic shunt when hepatic venous pressure gradient (HVPG) more than 10mmHg (Normal <5mmhg)>Development of collaterals including esophageal varices

Causes of CLD
- Alcohol
- Hepatitis B&C
- Aflatoxin
- Drugs - amiodarone methotrexate
- metabolic causes - wilson dz,hemochromatosis, alpha1 antitripsin deficiency,etc
-autoimmune - Primary biliary cirrhosis, primary sclerosing cholangitis

SELINGAN--> Causes of ACUTE liver failure
Viral hepatitis (A,B,C,D,E)
Drug reactions (halothane, isoniazide-rifampicin, antidepressants, NSAIDS, Valproic acid)
PCM overdose
Mushroom poisoning
Shock & multiorgan failure
Acute Bud-chiari syndrome
Wilson's disease
Fatty liver of pregnancy

Portosystemic shunt (Portal Tributaries) (Systemic tributaries)

Esophagus&gastric LEFT GASTRIC VEIN Azygous & Hemiazygous

Umbilicus Paraumbilical Vein in Falciform ligament Superficial ant abdominal vein

Anal Canal Sup rectal Vein Medial,inferior Rectal Vein

Retroperitoneal Venous radicals of: asc+desen colon, duodenum, pancreas
Retroperitoneal Veins: renal, suprarenal, gonadal, lumbar, phrenic veins

Bare Area of liver Portal branches veins of diaphragm

Child Pugh Score1 2 3
Encephalopathy NONE Minimal MARKED
Ascites NONE Slight MODERATE
Se bilirubin
se albumin

Risk factor of predictive rebleeding
- age>60
- degree of hepatic decompensation
- active bleeding of time of initial endoscopy
- severity of initial bleeding
- size of varices
- level of portal pressure
- renal insufficiency

Japanese classification of Esophageal Varices
Grade I: small straight varices not dissappearing with insufflations
Grade II: Medium varices occupying <1/3
Grade III: Large varices occupying more than 1/3 lumen

Acute Management:-
Stabilise patient hemodynamically
Take VS - BP, SPO2, RR
2 large bore IV branula & take blood for investigations
KNBM (prevent aspiration & for surgical intervention later if needed)
CBD - monitor input output
CVP - to monitor volume given as not to overload pt esp pt with heart problem

Investigations taken:

Blood transfusion should be given when:
Systolic BP <110mmhg>110/min)
Significant postural hypotension
hb <8g/dl> whole blood
otherwise--> pack cell
FFP if INR>1.5
platelet transfusion <50> for endoscopy ligation

Endoscopy sclerosant therapy has more SE: ulcer, stricture

Pharmacological - Vasoactive drugs (reduce pressure & flow within varices)
I list down based on generation
1) vasopressin (man made ADH) - increase blood pressure by causing vasoconstriction
has more systemic Se: MI, mesenteric ischemia, infarction

2)Somatostatin - produce by delta cell in pancreas
function: reduce blood flow to intestine. Half life: only 2 hours
SE: transient bradycardia, cramping
irreversible SE: thrombocytopeni, extrasystole

3) Octreotide (Somatostatin analogue) - half life-longer~ 8hours

4) Terlipressin (Vasopressin Analogue) - longer half life, fewer SE
Effective in control bleeding. shown to have more sustained hemodynamic effect compared to octreotide

Other modes of treatment if problem persist:
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
used only in uncontrolled variceal bleeding after combined pharmacological & endoscopic treatment

Pharmacological prophylaxis
non-selective Beta blocker~ Propanolol

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