The liver in pregnancy

Liver disease in pregnancy Liver function tests in pregnancy Hyperemesis gravidarum Obstetric cholestasis Acute fatty liver of pregnancy Pre-eclampsia HELLP syndrome Spontaneous hepatic rupture Gallstone disease Pancreatitis Budd–Chiari syndrome Viral hepatitis Pre-existing cirrhotic liver disease A number of liver disorders are unique to, or more likely to occur in, pregnancy. These should be considered alongside the other causes of liver disease that occur in non-pregnant patients. Transient mild derangements of LFT are common and rarely require further assessment beyond repeat monitoring to ensure normalization. However, liver disorders in pregnancy often present non-specifically and, therefore. all patients merit formal clinical assessment....

Complications of cirrhosis and portal hypertension

Causes and diagnosis of cirrhosis Causes and diagnosis of non-cirrhotic portal hypertension Ascites Spontaneous bacterial peritonitis Hepatorenal syndrome Variceal haemorrhage Hepatic encephalopathy Hepatopulmonary syndromes Hepatocellular carcinoma Cirrhosis occurs following progressive hepatic fibrosis, with architectural distortion of the liver and nodule formation. It is a histological diagnosis. Late-stage cirrhosis is irreversible, at which point only liver transplantation is curative. Early-stage cirrhosis has been shown to improve following treatment and may be asymptomatic....

Complications of nutritional support

Venous catheter-related problems Other complications of parenteral nutrition Problems with enteral tubes Re-feeding syndrome ● Above all else, ‘if the gut works, use it’. Only consider IV feeding if patients are likely to be without enteral nutrition for 〉5d. ● Central venous catheter feeding (i.e. catheter tip in SVC, IVC, or right atrium) preferred to avoid thrombophlebitis from hyperosmolar feeds. Well-managed central catheters can be left ...

Severe iron deficiency anaemia

Implication of iron deficiency Causes of iron deficiency Overt or occult bleeding Diagnosing iron deficiency Presentation and investigations Treatment Anaemia of chronic disease In the developed world, the commonest cause of iron deficiency anaemia (IDA) and its prelude iron deficiency is menstrual blood loss. Worldwide, hookworm infection is prevalent and causes IDA in those with heavy parasite load. About 4% of men/post-menopausal women have iron deficiency, and 1–2% have related IDA. Iron deficiency rises to ~20% in pre-menopausal women (remainder often have considerably reduced iron stores)....

Liver transplant patients

Management of liver transplant patients with abnormal LFT Early surgical complications Rejection Chronic biliary complications Infections Medical disorders Secondary malignancy Immunosuppressant medications Disease recurrence and long-term prognosis The management of chronic liver disease has been transformed by orthotopic and live-related liver transplantation. Early post-surgical outcomes are closely linked to preoperative performance status, quality of the donor organ, and surgical complexity. Advances in operative techniques and immunosuppressive therapies have improved survival to 90% at 1y, 70% at 5y, and 50% at 10y. The prevalence of long-term complications has correspondingly increased, many of which arise secondary to prolonged use of immunosuppressants....

Jaundice

Assessment and causes of jaundice Viral hepatitis Alcoholic hepatitis Drug-induced hepatitis Autoimmune hepatitis Haemochromatosis Wilson’s disease Primary biliary cirrhosis Ischaemic hepatitis Obstructive jaundice Acholuric jaundice Sepsis Jaundice refers to yellow pigmentation of the skin and sclera caused by elevated bilirubin levels. It is usually clinically detectable when serum bilirubin concentrations rise above 60...

HIV disease and the gastrointestinal tract

General principles Luminal disease Pancreatitis Hepatobiliary disease HIV-infected patients with low CD4 counts frequently develop acute GI and hepatobiliary disease. Whilst susceptible to the same disorders as immunocompetent patients, the differential diagnosis is broader. The aim is to identify treatable disorders. Clinical presentations are rarely specific, and patients usually require investigation rather than empiric treatment....

Drug-induced liver injury

Drug-induced liver injury Paracetamol Statins NSAIDs and aspirin Anticonvulsants Antidepressants Amiodarone Anti-tuberculosis drugs Co-amoxiclav Minocycline Oral contraceptive pill Khat Herbal remedies Drug-induced liver injury (DILI) accounts for ~1% of general medical admissions, 〈5% of all cases of jaundice, but up to 30% of acute liver failure. It is associated with 〉1,000 medications and herbal products. The following principles apply: ...

Complications of inflammatory bowel disease

Description of ulcerative colitis and Crohn’s disease Initial assessment of the patient with suspected IBD Assessing disease severity Management of ulcerative colitis Management of Crohn’s disease Special situations Complications of medical therapy Ulcerative colitis (UC) causes chronic inflammation of the rectum (proctitis) and colon (colitis). Caused by environmental triggers (possibly NSAIDs, infections, stress) in genetically susceptible hosts. Lifetime risk ~0.1% (1–2% if affected first-degree relative). Onset at any age, with bimodal distribution (15–30y and 50–70y). Presents with diarrhoea and rectal bleeding, followed by periods of remission and relapse. At any time, ~25% of patients are well (taking no medication), while two-thirds have mild disease requiring simple therapies (...

Gastroenteritis

Community-acquired gastroenteritis Specific pathogens Clostridium difficile-associated diarrhoea Travellers’ diarrhoea Parasitic infections Potential pitfalls Acute diarrhoea and vomiting are most frequently infectious in origin. In immunocompetent individuals, illness is typically self-limiting, with no intervention required beyond oral rehydration. If symptoms persist beyond 14d, they are classified as persistent, and often non-infectious or parasitic. Diarrhoea may be generated through osmotic, secretory or inflammatory mechanisms, or by increased motility. Infectious agents can elicit disease through any of these by mucosal adherence and invasion, or enterotoxin production....