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GASTRO (PANCREATITIS (ANTIBIOTICS - for severe acute pancreatitis…

- - - - Some evidence for education in extra hepatic infection with prophylaxis but no evidence for improved mortality or rates of pseudocyst infection. Likely to select for resistant organisms.
        
        Most antibiotics will not achieve MIC in necrotic tissue - Meropenem/Metronidazole/Ciprofloxaicn can. Aminoglycosodes and beta-lactams penetrate poorly.
        Guidelines state that prophylaxis not supported by evidence. Extra-hepatic infection should be treated with appropriate antibiotics, peri-pancreatic infections with Meropenem.
- - - - Test s - FBC/UEC, paracetamol level, LDH, CK urinary myoglobin, anti HAV, Hep A IgM, Hep B core antigen. Uric acid (raised in fatty liver of pregnancy.), COAGS (DIC in HELLP)EBV/CMV/HSV/VZV serology in immunosuppressed. Dengue and yellow fever serology in travellers, anti-SSM (AI hepatitis).TTE (heart failure - important in transplant workup), USS (vessel occlusion, liver rupture, gall bladder/stones), CT abdomen with contrast (mets/HCC), liver biopsy
        
        Physiology of ALF - SIRS/vasodilation/circulatory collapse - inducible NO due to exposure to bacterial endotoxin (failed liver dies - Kupffer cells no longer remove bacteria from blood leading to endotoxin exposure/bacteraemia/sepsis. ALI/ARDS - massive exposure to pro-inflame cytokines - permissive hypercapnia may be precluded by raised ICP. Portopulmonary shunt, hepatopulmonary syndrome (failure of hypoxic pulmonary. vasoconstriction due to NO - orthodeoxia - hypoxic on standing). Hepatic encephalopathy and raised ICP (astrocytes convert excess ammonia into glutamine this create an osmotic gradient that pulls water into the cell and increases volume by approx. 127%), hyper catabolic state and increased nutritional req. hyperlactaemic metabolic acidosis. Hypoglycaemia, renal failure and hepatorenal syndrome, coagulopathy, bone marrow suppression, immune dysfunction (decreased complement synthesis, defective opsonisation, impaired neutrophil function.
        
        Hepatorenal syndrome - cirrhosis, ascites, creat >150, absence of shock, no current or recent nephrotoxic drugs, no parenchymal kidney disease.
        
        MANAGEMENT - Specific therapies - Paracetamol - NAC, Wislons disease - Copper chelating agents, Hepatic venous thrombosis (thrombolysis/clot retrieval/TIPS) Hepatic viruses - anti-virals. AI - steroids, ETOH - ?steroids, Valproate OD - L-carnitine, amanita phalloides - CVVHDF
        
        MANAGEMENT GENERAL SUPPORTIVE - Intubate to protect A, hyperventilate to low normal CO2 (35mmHg) for ICP, Vasopressors (avoid fluid overload), Sedate with short acting drugs e.g. Propofol, consider ICP monitor (surprisingly safe in context of factor VIIa 1 hr prior. Hypothermia, hyperventilation, hypernatraemia, haemodiafiltration (for ammonia removal) (HHHH). Fluid resuscitate with crystalloid, dextrose infusion, enteral lactulose - interferes with bacterial ammonia production by providing simple sugars that they preferentially metabolise over amino acids and promotes bowel motility, PPI(GI bleeds), drain ascites if tense(similar to gravid uterus), anticipate coagulopathy = vitamin K. Vigilant surveillance for sepsis and early ABx's. +/- Rifamyxin for reduction of gut flora.