Congestive Hepatic Fibrosis Score
Total Page:16
File Type:pdf, Size:1020Kb
Load more
Recommended publications
-
Evaluation of Abnormal Liver Chemistries
ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries Paul Y. Kwo, MD, FACG, FAASLD1, Stanley M. Cohen, MD, FACG, FAASLD2, and Joseph K. Lim, MD, FACG, FAASLD3 1Division of Gastroenterology/Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA; 2Digestive Health Institute, University Hospitals Cleveland Medical Center and Division of Gastroenterology and Liver Disease, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; 3Yale Viral Hepatitis Program, Yale University School of Medicine, New Haven, Connecticut, USA. Am J Gastroenterol 2017; 112:18–35; doi:10.1038/ajg.2016.517; published online 20 December 2016 Abstract Clinicians are required to assess abnormal liver chemistries on a daily basis. The most common liver chemistries ordered are serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase and bilirubin. These tests should be termed liver chemistries or liver tests. Hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with alkaline phosphatase levels. Cholestatic injury is defined as disproportionate elevation of alkaline phosphatase level as compared with AST and ALT levels. The majority of bilirubin circulates as unconjugated bilirubin and an elevated conjugated bilirubin implies hepatocellular disease or cholestasis. Multiple studies have demonstrated that the presence of an elevated ALT has been associated with increased liver-related mortality. A true healthy normal ALT level ranges from 29 to 33 IU/l for males, 19 to 25 IU/l for females and levels above this should be assessed. The degree of elevation of ALT and or AST in the clinical setting helps guide the evaluation. -
Inside the Minds: the Art and Science of Gastroenterology
Gastroenterology_ptr.qxd 8/24/07 11:29 AM Page 1 Inside the Minds ™ Inside the Minds ™ The Secrets to Success in The Art and Science of Gastroenterology Gastroenterology The Art and Science of Gastroenterology is an authoritative, insider’s perspective on the var- ious challenges in this field of medicine and the key qualities necessary to become a successful Top Doctors on Diagnosing practitioner. Featuring some of the nation’s leading gastroenterologists, this book provides a Gastroenterological Conditions, Educating candid look at the field of gastroenterology—academic, surgical, and clinical—and a glimpse Patients, and Conducting Clinical Research into the future of a dynamic practice that requires a deep understanding of pathophysiology and a desire for lifelong learning. As they reveal the secrets to educating and advocating for their patients when diagnosing their conditions, these authorities offer practical and adaptable strategies for excellence. From the importance of soliciting a thorough medical history to the need for empathy towards patients whose medical problems are not outwardly visible, these doctors articulate the finer points of a profession focused on treating disorders that dis- rupt a patient’s lifestyle. The different niches represented and the breadth of perspectives presented enable readers to get inside some of the great innovative minds of today, as experts offer up their thoughts around the keys to mastering this fine craft—in which both sensitiv- ity and strong scientific knowledge are required. ABOUT INSIDETHE MINDS: Inside the Minds provides readers with proven business intelligence from C-Level executives (Chairman, CEO, CFO, CMO, Partner) from the world’s most respected companies nationwide, rather than third-party accounts from unknown authors and analysts. -
Acute Liver Failure J G O’Grady
148 Postgrad Med J: first published as 10.1136/pgmj.2004.026005 on 4 March 2005. Downloaded from REVIEW Acute liver failure J G O’Grady ............................................................................................................................... Postgrad Med J 2005;81:148–154. doi: 10.1136/pgmj.2004.026005 Acute liver failure is a complex multisystemic illness that account for most cases, but a significant number of patients have no definable cause and are evolves quickly after a catastrophic insult to the liver classified as seronegative or of being of indeter- leading to the development of encephalopathy. The minate aetiology. Paracetamol is the commonest underlying aetiology and the pace of progression strongly cause in the UK and USA.2 Idiosyncratic reac- tions comprise another important group. influence the clinical course. The commonest causes are paracetamol, idiosyncratic drug reactions, hepatitis B, and Viral seronegative hepatitis. The optimal care is multidisciplinary ALF is an uncommon complication of viral and up to half of the cases receive liver transplants, with hepatitis, occurring in 0.2%–4% of cases depend- ing on the underlying aetiology.3 The risk is survival rates around 75%–90%. Artificial liver support lowest with hepatitis A, but it increases with the devices remain unproven in efficacy in acute liver failure. age at time of exposure. Hepatitis B can be associated with ALF through a number of ........................................................................... scenarios (table 2). The commonest are de novo infection and spontaneous surges in viral repli- cation, while the incidence of the delta virus cute liver failure (ALF) is a complex infection seems to be decreasing rapidly. multisystemic illness that evolves after a Vaccination should reduce the incidence of Acatastrophic insult to the liver manifesting hepatitis A and B, while antiviral drugs should in the development of a coagulopathy and ameliorate replication of hepatitis B. -
Nutrition Considerations in the Cirrhotic Patient
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #204 NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #204 Carol Rees Parrish, MS, RDN, Series Editor Nutrition Considerations in the Cirrhotic Patient Eric B. Martin Matthew J. Stotts Malnutrition is commonly seen in individuals with advanced liver disease, often resulting from a combination of factors including poor oral intake, altered absorption, and reduced hepatic glycogen reserves predisposing to a catabolic state. The consequences of malnutrition can be far reaching, leading to a loss of skeletal muscle mass and strength, a variety of micronutrient deficiencies, and poor clinical outcomes. This review seeks to succinctly describe malnutrition in the cirrhosis population and provide clarity and evidence-based solutions to aid the bedside clinician. Emphasis is placed on screening and identification of malnutrition, recognizing and treating barriers to adequate food intake, and defining macronutrient targets. INTRODUCTION The Problem ndividuals with cirrhosis are at high risk of patients to a variety of macro- and micronutrient malnutrition for a multitude of reasons. Cirrhotic deficiencies as a consequence of poor intake and Ilivers lack adequate glycogen reserves, therefore altered absorption. these individuals rely on muscle breakdown as an As liver disease progresses, its complications energy source during overnight periods of fasting.1 further increase the risk for malnutrition. Large Well-meaning providers often recommend a variety volume ascites can lead to early satiety and decreased of dietary restrictions—including limitations on oral intake. Encephalopathy also contributes to fluid, salt, and total calories—that are often layered decreased oral intake and may lead to inappropriate onto pre-existing dietary restrictions for those recommendations for protein restriction. -
Does Your Patient Have Bile Acid Malabsorption?
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #198 NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #198 Carol Rees Parrish, MS, RDN, Series Editor Does Your Patient Have Bile Acid Malabsorption? John K. DiBaise Bile acid malabsorption is a common but underrecognized cause of chronic watery diarrhea, resulting in an incorrect diagnosis in many patients and interfering and delaying proper treatment. In this review, the synthesis, enterohepatic circulation, and function of bile acids are briefly reviewed followed by a discussion of bile acid malabsorption. Diagnostic and treatment options are also provided. INTRODUCTION n 1967, diarrhea caused by bile acids was We will first describe bile acid synthesis and first recognized and described as cholerhetic enterohepatic circulation, followed by a discussion (‘promoting bile secretion by the liver’) of disorders causing bile acid malabsorption I 1 enteropathy. Despite more than 50 years since (BAM) including their diagnosis and treatment. the initial report, bile acid diarrhea remains an underrecognized and underappreciated cause of Bile Acid Synthesis chronic diarrhea. One report found that only 6% Bile acids are produced in the liver as end products of of British gastroenterologists investigate for bile cholesterol metabolism. Bile acid synthesis occurs acid malabsorption (BAM) as part of the first-line by two pathways: the classical (neutral) pathway testing in patients with chronic diarrhea, while 61% via microsomal cholesterol 7α-hydroxylase consider the diagnosis only in selected patients (CYP7A1), or the alternative (acidic) pathway via or not at all.2 As a consequence, many patients mitochondrial sterol 27-hydroxylase (CYP27A1). are diagnosed with other causes of diarrhea or The classical pathway, which is responsible for are considered to have irritable bowel syndrome 90-95% of bile acid synthesis in humans, begins (IBS) or functional diarrhea by exclusion, thereby with 7α-hydroxylation of cholesterol catalyzed interfering with and delaying proper treatment. -
Hepatology Curriculum
Hepatology Curriculum The rotation in Hepatology will be for a minimum of 3 months during the first two years of the Gastroenterology Fellowship The purpose of Level I training is to develop a basic understanding of and familiarity with the principles and practice of Hepatology. The trainee should acquire sufficient experience to function completely as a consultant in the field. This training however, does not entitle the trainee to claim expertise sufficient to function solely as a clinical/academic Hepatologist or a transplant Hepatologist. It is anticipated that the Fellow will receive broad clinical experience encompassing a variety of Hepatobiliary disorders and behavioral adjustments of patients to their hepatic disease. Fellows will gain experience with a wide array of therapeutic interventions and the appropriate utilization of laboratory tests including interpretation of live biopsy specimens and interventional procedures. Fellows will gain experience with liver transplant patients. In addition to this on-going clinical service or activity, the Fellow will also be exposed to clinical and basic research and will participate in conferences designed to address aspects of clinical and basic Hepatology. Specific Program Content: The following material is abstracted from an article entitled Guidelines for Training in Hepatology, Hepatology 1992: 16:4:1084-1086 Objectives: 1) During the course of the GI Fellowship the Fellow will come to understand: a) Biology and pathobiology of the liver b) Clinical management of patients with Hepatobiliary diseases, including: 1. Viral hepatitis 2. Fulminant hepatic failure 3. Complications of chronic liver disease 4. Gallstone disease 5. Hepatobiliary disorders of pregnancy 6. Preoperative evaluation of patients with hepatobiliary diseases 7. -
Diarrhea Gastroenterology
Diarrhea Referral Guide: Gastroenterology Page 1 of 2 Diagnosis/Definition: The rectal passage of an increased number of stools per day which are watery, bloody or loosely formed. By history and stool sample. Initial Diagnosis and Management: Most patients don’t need to be worked up for their diarrhea. Most cases of diarrhea are self-limiting, caused by a gastroenteritis viral agent. Patients need to be advised to drink plenty of fluids, take some NSAIDSs or Tylenol for fevers and flu-related myalgias. If the patient comes to you with a history of bloody diarrhea, fever, severe abdominal pain, and diarrhea longer than 2 weeks or associated with electrolyte abnormalities or is elderly or immunocompromised, they need to be seen by GI. Work-up in these patients should consist of a thorough history (be sure to get travel history, medications including herbal remedies and possible infectious contacts) and physical examination. Labs should include a chem. 7, CBC with differential and stool WBCs, cultures, qualitative fecal fat. If there is the possibility that this could be antibiotic related C. difficile then order a C. diff toxin on the stool. Only order an O and P on the stool\l if the patient gives you a recent history of international travel, wildern4ess camping/hiking or may be immunocompromised. Make sure to ask about mil product ingestion as it relates to the diarrhea. Fifty percent of adult Caucasians and up to 90% of African Americans, Hispanics, and Asians have some degree of milk intolerance. If from your history and laboratory studies indicate a specific etiology the following chart may help with initial therapy. -
Children's Gastroenterology, Hepatology, and Nutrition
GI_InsertCard 4/24/09 2:03 PM Page 1 CHILDREN’S GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION CONSULT AND REFERRAL GUIDELINES FOR COMMON GI PROBLEMS DIAGNOSIS/SYMPTOM SUGGESTIONS FOR POSSIBLE PRE-REFERRAL CONSIDER INITIAL WORK-UP THERAPY REFERRAL WHEN CHRONIC ABDOMINAL PAIN ICD-9 code – 789.0 • Weight and height percentiles • Treatment of constipation, If symptoms persist after Age: toddler to adolescence • Urinanalysis if present improvement of stooling • CBC with dif ESR or CRP • Acid suppression - H2 receptor pattern, trial of a lactose-free • Stool Studies: • Antagonist or proton pump diet and lack of response – guaiac • Inhibitor to acid suppression, referral – consider EIA antigen for giardia • Trial off lactose should be made. The child • Careful evaluation of stooling pattern may require endoscopy • Diary to look for possible triggers such as foods, (EGD) and/or colonoscopy. activities or stressors CHRONIC, NON-BLOODY DIARRHEA ICD-9 code – 787.91 • Weight and height percentiles • Treat any dietary abnormality If Symptoms persist, referral Age: preschool to adolescence • Stool studies: (e.g. high fructose and/or low fat) should be made. The child – guaiac • Try increased fiber in diet may require EGD and/or – consider leukocytes • Diary of dairy and other food colonoscopy. – culture intake in relation to symptoms – EIA antigen for giardia – C. difficile toxin titer – Reducing substances, pH, – Sudan stain (spot test for fecal fat) • CBC with differential, ESR or CRP • Albumin • Quantitative IgA and anti-tTG Antibody (screen for celiac) • Consider sweat test • Consider upper GI with small bowel follow through • Consider laxative abuse, especially in adolescent females BLOODY DIARRHEA (COLITIS) ICD-9 code – 556 • Stool studies: If evaluation is negative, food If symptoms persist, referral Age: infancy – guaiac protein allergy is likely. -
A Practical Approach to Management of Acute Pancreatitis: Similarities and Dissimilarities of Disease in Children and Adults
Journal of Clinical Medicine Review A Practical Approach to Management of Acute Pancreatitis: Similarities and Dissimilarities of Disease in Children and Adults Zachary M. Sellers 1 , Monique T. Barakat 1,2 and Maisam Abu-El-Haija 3,4,* 1 Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA 94304, USA; [email protected] (Z.M.S.); [email protected] (M.T.B.) 2 Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA 94304, USA 3 Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA 4 Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45221, USA * Correspondence: [email protected]; Tel.: +1-(513)-803-2123; Fax: +1-(513)-487-5528 Abstract: Acute pancreatitis (AP) is associated with significant morbidity and mortality, and it substantially contributes to the healthcare burden of gastrointestinal disease and quality of life in children and adults. AP across the lifespan is characterized by similarities and differences in epidemiology, diagnostic modality, etiologies, management, adverse events, long-term outcomes, and areas in greatest need of research. In this review, we touch on each of these shared and distinctive features of AP in children and adults, with an emphasis on recent advances in the conceptualization Citation: Sellers, Z.M.; Barakat, M.T.; and management of AP. Abu-El-Haija, M. A Practical Approach to Management of Acute Keywords: acute pancreatitis; management; outcomes; gastrointestinal disease Pancreatitis: Similarities and Dissimilarities of Disease in Children and Adults. J. Clin. Med. 2021, 10, 2545. -
Liver Dysfunction in the Intensive Care Unit ANNALS of GASTROENTEROLOGY 2005, 18(1):35-4535
Liver dysfunction in the intensive care unit ANNALS OF GASTROENTEROLOGY 2005, 18(1):35-4535 Review Liver dysfunction in the intensive care unit Aspasia Soultati, S.P. Dourakis SUMMARY crosis factor-alpha, is pivotal for the development of liver injury at that stage. Liver dysfunction plays a significant role in the Intensive Care Unit (ICU) patients morbidity and mortality. Although determinations of aminotransferases, coagulation Metabolic, hemodynamic and inflammatory factors studies, glucose, lactate and bilirubin can detect hepatic contribute in liver damage. Hemorrhagic shock, septic shock, injury, they only partially reflect the underlying pathophys- multiple organ dysfunction, acute respiratory dysfunction, iological mechanisms. Both the presence and degree of jaun- metabolic disorders, myocardial dysfunction, infection from dice are associated with increased mortality in a number of hepatitis virus, and therapeutic measures such as blood non hepatic ICU diseases. transfusion, parenteral nutrition, immunosuppresion, and Therapeutic approaches to shock liver focus on the drugs are all recognised as potential clinical situations on prevention of precipitating causes. Prompt resuscitation, the grounds of which liver dysfunction develops. definitive treatment of sepsis, meticulous supportive care, The liver suffers the consequences of shock- or sepsis-in- controlling of circulation parameters and metabolism, in ducing circumstances, which alter hepatic circulation pa- addition to the cautious monitoring of therapeutic measures rameters, oxygen supply and inflammatory responses at the such as intravenous nutrition, mechanical ventilation and cellular level. Moreover, the liver is an orchestrator of met- catecholamine administration reduce the incidence and abolic arrangements which promote the clearance and pro- severity of liver dysfunction. Only precocious measures can duction of inflammatory mediators, the scavenging of bac- be taken to prevent hepatitis in ICU. -
The Short History of Gastroenterology
JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2003, 54, S3, 921 www.jpp.krakow.pl A. RÓDKA THE SHORT HISTORY OF GASTROENTEROLOGY Department of History of Medicine, Jagiellonian University Medical College Cracow, Poland In this paper research on the stomach and bowel physiology is presented in a historical perspective. The author tries to show how digestive processes were interpreted by the ancients and how they tried to adjust them to the dominating humoral theory of disease. It is pointed out that the breakthrough which created a new way of understanding of the function of the digestive system was made by Andreas Vesalius and his modern model of anatomy. The meaning of acceptance of chemical processes in digestion by iatrochemics representatives in XVII century is shown. Physiological research in XIX century, which decided about a rapid development of physiology, especially the physiology of the gastrointestinal tract, is discussed. Experiments were performed by all main representatives of this discipline: Claude Bernard, Jan Ewangelista Purkynì, Rudolph Heidenhain and especially Ivan Pavlov, who, thanks to the discoveries in the secretion physiology, explained basic functions of the central nervous system. The XX century was dominated by the research showing the important role of the endocrine system and biological agents in the regulation of secretion and motility of the digestive system. The following discoveries are discussed: Ernest Sterling (secretin), John Edkins (gastrin) and André Latarjet and Lester Dragstedt (acetylcholine). It is underlined that Polish scientists play an important role in the development of the gastroenterological science - among others; Walery Jaworski, who made a historical suggestion about the role of the spiral bacteria in etiopathogenesis of the peptic ulcer, Leon Popielski, who stated the stimulating influence of histamine on the stomach acid secretion, Julian Walawski, who discovered enterogastrons - hormones decreasing secretion. -
Dos and Don'ts in the Management of Cirrhosis: a View from the 21St
THE RED SECTION 1 see related editorial on page x Dos and Don’ts in the Management of Cirrhosis: IT H A View from the 21st Century C A Mary J. Tomson, MD1,2, Elliot B. Tapper, MD1,2,3 and Anna S.F. Lok, MD1,2 Am J Gastroenterol https://doi.org/10.1038/s41395-018-0028-5 Cirrhosis is a morbid, multisystem disease associated with fre- (creatinine ≥1.2 or sodium ≤130 mmol/L) and an ascitic fuid quent hospitalizations and high mortality rates. Te number of total protein <1.5 g/dL [4]. afected people is rising in the United States, refected in a 59% HOW I APPRO increase in patients with cirrhosis seeking medical care in the past decade [1]. Anticipating and preventing many of the complica- ACT QUICKLY FOR SUSPECTED VARICEAL BLEEDING AND tions of cirrhosis can be challenging. To aid gastroenterologists DONT FORGET SECONDARY PROPHYLAXIS TO PREVENT caring for this booming population, we propose the following RECURRENT BLEEDING “Dos and Don’ts” for management of cirrhosis in the inpatient Patients with cirrhosis and upper gastrointestinal hemorrhage and outpatient settings (Table 1). should undergo upper endoscopy within 12 h of presentation (Fig. 2). Prior to endoscopy, all patients should receive vasoactive agents and antibiotics. As patients with cirrhosis and gastrointes- ALL PATIENTS WITH ASCITES ADMITTED TO THE tinal bleeding are at high risk for bacterial infections (not limited HOSPITAL SHOULD HAVE A DIAGNOSTIC PARACENTESIS, to SBP), antibiotics should be provided even if patients do not REGARDLESS OF COAGULOPATHY have ascites [5]. Spontaneous bacterial peritonitis (SBP) is ofen asymptomatic and Patients who had a variceal bleed are at high risk for recurrent early treatment is associated with improved outcomes.