Gastrointestinal Emergencies Dr Richard Warner SpR Gastroenterology September 2005
GI emergencies <ul><li>GI bleeding </li></ul><ul><li>Paracetamol Overdose </li></ul><ul><li>Severe ulcerative colitis/Croh...
Upper GI Bleeding <ul><li>Incidence 100/100,000 </li></ul><ul><li>Mortality - 1947 9.9%, 1995 11% (6%), 33% (17%) in hospi...
Causes of Upper GI Bleeding <ul><li>peptic ulceration (35-50%) </li></ul><ul><li>oesophagitis, gastritis, duodenitis (5-15...
Varices
Varices
Varices
Oesophagitis
Mallory Weiss Tear
Gastric ulceration
Angiodysplasia
Duodenal Ulceration
Symptoms at Presentation <ul><li>haematemesis/melaena/both </li></ul><ul><li>breathlessness, chest pain </li></ul><ul><li>...
Management of Upper GI Bleed <ul><li>Resuscitation </li></ul><ul><li>Assessment of vital signs </li></ul><ul><li>wide bore...
Factors in History <ul><li>NSAIDs, clopidogrel, steroids </li></ul><ul><li>alcohol history </li></ul><ul><li>liver disease...
Severe UGI Bleed/ High risk <ul><li>Haematemesis and melaena </li></ul><ul><li>cardiovascular compromise  </li></ul><ul><l...
 
 
Rockall Scoring System (Risk of rebleeding and death)
Rockall Scoring System 2 <ul><li>Score less than 3 = excellent prognosis </li></ul><ul><li>?fast tracked for discharge </l...
Endoscopy for UGI Bleeding <ul><li>Diagnostic and therapeutic </li></ul><ul><li>Peptic ulceration  - injection, heater pro...
Evidence for Intravenous Omeprazole <ul><li>Lau et al 2000  (NEJM) </li></ul><ul><li>15-20% rebleeding rate for peptic ulc...
Variceal Bleeding <ul><li>Mortality 30-80% (average 50%) </li></ul><ul><li>?Severity underlying liver disease (A<B<C) </li...
Therapy for Varices <ul><li>Endoscopic - banding or sclerotherapy </li></ul><ul><li>Medical - terlipressin, octreotide </l...
Endoscopic Therapy of Varices <ul><li>Sclerotherapy control of bleeding </li></ul><ul><li>Band Ligation 1995  Lo demonstra...
Medical Therapy of Bleeding Varices <ul><li>vasopressin/glypressin  +/-  GTN  increased rate control of bleeding, no benef...
Sengstaken
 
Primary and Secondary Prevention of Variceal Bleeding <ul><li>Betablockers -  propanolol 40-80mg bd </li></ul><ul><li>Prim...
Role of Beta-blockers <ul><li>Decrease portal pressure, splanchnic vasoconstriction </li></ul><ul><li>Primary 9 RCT, 1 met...
TIPPS
Transjugular Intrahepatic  Porto-systemic Shunt <ul><li>Refractory variceal bleeding </li></ul><ul><li>refractory ascites ...
Complications of TIPSS <ul><li>Restenosis, occlusion (rebleeding) </li></ul><ul><li>thromboembolism </li></ul><ul><li>hepa...
Variceal Bleed Treatment Plan <ul><li>Resuscitation and early endoscopy </li></ul><ul><li>Banding +/-sclerotherapy </li></...
Lower GI Bleeding <ul><li>Diverticular disease </li></ul><ul><li>Adenoma/Carcinoma </li></ul><ul><li>Colitis </li></ul><ul...
 
Paracetamol Overdose <ul><li>15g potentially lethal </li></ul><ul><li>conjugates  sulphate and glucuronide </li></ul><ul><...
High risk paracetamol overdoses <ul><li>Pre-existing liver disease </li></ul><ul><li>high alcohol intake </li></ul><ul><li...
 
Paracetamol OD Symptoms <ul><li>Usually after 24 hours </li></ul><ul><li>anorexia, nausea, vomiting </li></ul><ul><li>day ...
Complications of Paracetamol Overdose <ul><li>Jaundice and FHF </li></ul><ul><li>renal failure (ATN) </li></ul><ul><li>hyp...
Management of Paracetamol OD <ul><li>? level    4hours </li></ul><ul><li>lower significant level if high risk </li></ul><...
Prognostic factors <ul><li>PTT >100s (PTT >180s < 8% survival) </li></ul><ul><li>pH <7.30 (15% survival) </li></ul><ul><li...
 
Severe Ulcerative colitis <ul><li>Truelove and Witt’s Criteria of severity </li></ul><ul><li>bowel frequency >6/day, blood...
Symptoms severe UC  <ul><li>? systemically unwell </li></ul><ul><li>Fever </li></ul><ul><li>Abdominal pain </li></ul><ul><...
 
 
Assessment of severe UC <ul><li>Stool cultures </li></ul><ul><li>Blood tests - FBC, U&Es, ESR, LFTs,    albumin, CRP  </li...
Management of Severe UC <ul><li>Joint physician/surgeons </li></ul><ul><li>high dose intravenous steroids </li></ul><ul><l...
Course of Severe UC <ul><li>25% severe colitics considered for colectomy </li></ul><ul><li>urgent colectomy if complicatio...
Crohn’s colitis <ul><li>High dose iv steroids +/- rectal steroids </li></ul><ul><li>Antibiotics - metronidazole </li></ul>...
 
 
 
Liver Failure/Decompensation <ul><li>History is crucial </li></ul><ul><li>Establish Childs score </li></ul><ul><li>Ascites...
Decompensation <ul><li>GI Bleed </li></ul><ul><li>Sepsis </li></ul><ul><li>Drugs </li></ul><ul><li>Constipation </li></ul>...
Investigations <ul><li>FBC/MCV </li></ul><ul><li>Clotting </li></ul><ul><li>U+Es </li></ul><ul><li>Albumin + LFTs </li></u...
Investigations <ul><li>Ascitic diagnostic tap </li></ul><ul><li>Blood Cultures </li></ul><ul><li>Urine Cultures </li></ul>...
Treatment <ul><li>Stop all sedating/toxic drugs </li></ul><ul><li>Laxatives </li></ul><ul><li>Antibiotics </li></ul><ul><l...
Ascites is not just a Cosmetic Problem ! <ul><li>Median Survival 2 years from onset </li></ul><ul><li>Survival depends mai...
SBP <ul><li>No Set Rules! </li></ul><ul><li>? Drain </li></ul><ul><li>3 x 100mls 20% salt poor HAS day 1+2 </li></ul><ul><...
 
Hepatorenal syndrome Splanchnic vasodilatation Effective underfilling Salt and water retention Vasoconstrictor systems Ren...
Hepatorenal syndrome <ul><li>Diagnosis </li></ul><ul><ul><li>Diagnosis according to strict criteria  (IAC 1996) </li></ul>...
Treatment options <ul><li>Vasoconstrictors </li></ul><ul><ul><li>Terlipressin </li></ul></ul><ul><ul><li>Noradrenaline </l...
Hepatorenal syndrome <ul><li>Terlipressin with albumin </li></ul><ul><ul><li>Long acting vasopressin analague, splanchnic ...
Hepatorenal syndrome <ul><li>Noradrenaline </li></ul><ul><ul><li>N=12 </li></ul></ul><ul><ul><li>0.5-3mg/h + albumin + fru...
Hepatorenal syndrome <ul><li>Midodrine and octreotide </li></ul><ul><ul><ul><li>N= 13 Type 1 HRS  </li></ul></ul></ul><ul>...
Hepatorenal syndrome <ul><li>TIPSS </li></ul><ul><ul><ul><li>41 non transplant candidates  ( non randomised) </li></ul></u...
Hepatorenal Syndrome <ul><li>TIPSS </li></ul><ul><ul><li>Type 2 HRS </li></ul></ul><ul><ul><ul><li>N=18 Type 2 HRS CP C </...
Hepatorenal Syndrome <ul><li>Medical therapy as a Bridge to TIPSS </li></ul><ul><ul><ul><li>N=14, Type 1 HRS, M+O 14 days ...
Hepatorenal syndrome <ul><li>Effect of HRS upon outcome of OLT </li></ul><ul><ul><li>N=9 HRS with terlipressin Rx </li></u...
Hepatorenal syndrome <ul><li>Summary </li></ul><ul><ul><li>Terlipressin with plasma expansion </li></ul></ul><ul><ul><li>I...
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  • Gastrointestinalemergencies Richard

    1. 1. Gastrointestinal Emergencies Dr Richard Warner SpR Gastroenterology September 2005
    2. 2. GI emergencies <ul><li>GI bleeding </li></ul><ul><li>Paracetamol Overdose </li></ul><ul><li>Severe ulcerative colitis/Crohn’s colitis </li></ul><ul><li>Liver Failure </li></ul>
    3. 3. Upper GI Bleeding <ul><li>Incidence 100/100,000 </li></ul><ul><li>Mortality - 1947 9.9%, 1995 11% (6%), 33% (17%) in hospitalised patients </li></ul><ul><li>Higher MR in elderly with co-morbidity </li></ul>
    4. 4. Causes of Upper GI Bleeding <ul><li>peptic ulceration (35-50%) </li></ul><ul><li>oesophagitis, gastritis, duodenitis (5-15%) </li></ul><ul><li>gastroduodenal erosions (8-15%) </li></ul><ul><li>Mallory Weiss tear (15%) </li></ul><ul><li>varices (5-10%) </li></ul><ul><li>tumour (1%) </li></ul><ul><li>angiodysplasia, telangiectasia (2-3%) </li></ul><ul><li>vascular ectasia, Dieulafoy’s lesion(1-2%) </li></ul>
    5. 5. Varices
    6. 6. Varices
    7. 7. Varices
    8. 8. Oesophagitis
    9. 9. Mallory Weiss Tear
    10. 10. Gastric ulceration
    11. 11. Angiodysplasia
    12. 12. Duodenal Ulceration
    13. 13. Symptoms at Presentation <ul><li>haematemesis/melaena/both </li></ul><ul><li>breathlessness, chest pain </li></ul><ul><li>collapse </li></ul>
    14. 14. Management of Upper GI Bleed <ul><li>Resuscitation </li></ul><ul><li>Assessment of vital signs </li></ul><ul><li>wide bore venous cannulae/?central line </li></ul><ul><li>crystalloid, colloid/blood </li></ul><ul><li>blood tests and cross match </li></ul><ul><li>monitoring - bp, hr, urine output, ?cvp </li></ul><ul><li>early endoscopy and inform surgeons </li></ul><ul><li>high dose iv ppi for peptic ulcers </li></ul>
    15. 15. Factors in History <ul><li>NSAIDs, clopidogrel, steroids </li></ul><ul><li>alcohol history </li></ul><ul><li>liver disease </li></ul><ul><li>anticoagulants </li></ul><ul><li>family history </li></ul><ul><li>severe vomiting </li></ul>
    16. 16. Severe UGI Bleed/ High risk <ul><li>Haematemesis and melaena </li></ul><ul><li>cardiovascular compromise </li></ul><ul><li>age>65 </li></ul><ul><li>co-existing cardiorespiratory disease </li></ul><ul><li>Hb <10g/l </li></ul>
    17. 19. Rockall Scoring System (Risk of rebleeding and death)
    18. 20. Rockall Scoring System 2 <ul><li>Score less than 3 = excellent prognosis </li></ul><ul><li>?fast tracked for discharge </li></ul><ul><li>score > 8 = high mortality risk </li></ul><ul><li>close monitoring </li></ul><ul><li>stratified post endoscopy </li></ul>
    19. 21. Endoscopy for UGI Bleeding <ul><li>Diagnostic and therapeutic </li></ul><ul><li>Peptic ulceration - injection, heater probe, haemoclips </li></ul><ul><li>high risk - actively bleeding vessel (0-75%) </li></ul><ul><li>non-bleeding visible vessel (4-27%) </li></ul><ul><li>adherent clot </li></ul><ul><li>therapy  rebleeding, surgery, mortality </li></ul>
    20. 22. Evidence for Intravenous Omeprazole <ul><li>Lau et al 2000 (NEJM) </li></ul><ul><li>15-20% rebleeding rate for peptic ulcers </li></ul><ul><li>80mg bolus, 8mg/hour for 72 hours, 20mg </li></ul><ul><li>orally for 8 weeks </li></ul><ul><li>adrenaline+thermocoagulation, randomised to ppi (120) or placebo (120) (30 day FU) </li></ul><ul><li>rebleeding in placebo 22.5% (20% ), omeprazole 6.7% (4%) </li></ul>
    21. 23. Variceal Bleeding <ul><li>Mortality 30-80% (average 50%) </li></ul><ul><li>?Severity underlying liver disease (A<B<C) </li></ul><ul><li>50% rebleed in 10 days </li></ul><ul><li>30-50% cirrhotics have a variceal bleed </li></ul><ul><li>40-80% rebleed in 1 year </li></ul><ul><li>33% survive 3 years </li></ul><ul><li>no bleed if portal pressure <12mmHg </li></ul>
    22. 24. Therapy for Varices <ul><li>Endoscopic - banding or sclerotherapy </li></ul><ul><li>Medical - terlipressin, octreotide </li></ul><ul><li>Tamponade - Sengstaken-Blakemore tube </li></ul><ul><li>Surgery - shunts, oesophageal transection </li></ul><ul><li>TIPSS </li></ul>
    23. 25. Endoscopic Therapy of Varices <ul><li>Sclerotherapy control of bleeding </li></ul><ul><li>Band Ligation 1995 Lo demonstrated band ligation better than sclerotherapy (94%:80%) 1998 Stiegmann demonstrated control of bleeding decreased rate of complications, decreased MR compared to sclerotherapy </li></ul>
    24. 26. Medical Therapy of Bleeding Varices <ul><li>vasopressin/glypressin +/- GTN increased rate control of bleeding, no benefit survival </li></ul><ul><li>somatostatin / octreotide increased rate control of bleeding, improved survival </li></ul><ul><li>somatostatin=sclerotherapy=tamponade </li></ul>
    25. 27. Sengstaken
    26. 29. Primary and Secondary Prevention of Variceal Bleeding <ul><li>Betablockers - propanolol 40-80mg bd </li></ul><ul><li>Primary - screen cirrhotics </li></ul><ul><li>?prophylactic banding (Gastro 2002) </li></ul><ul><li>Secondary - once bleed settled </li></ul><ul><li>Aiming portal pressure <12mmHg/  20% </li></ul>
    27. 30. Role of Beta-blockers <ul><li>Decrease portal pressure, splanchnic vasoconstriction </li></ul><ul><li>Primary 9 RCT, 1 meta-analysis </li></ul><ul><li>significant decrease in risk of bleeding </li></ul><ul><li>cirrhotics screened, if varices start  blocker </li></ul><ul><li>Secondary 755 patients in 11 trials significant decrease in rebleeding rates </li></ul>
    28. 31. TIPPS
    29. 32. Transjugular Intrahepatic Porto-systemic Shunt <ul><li>Refractory variceal bleeding </li></ul><ul><li>refractory ascites </li></ul><ul><li>Budd-Chiari </li></ul><ul><li>95-100% success rate </li></ul><ul><li>0-2% procedural mortality, 10% morbidity </li></ul><ul><li>30 day mortality 5-15% </li></ul><ul><li>bridge to transplantation </li></ul>
    30. 33. Complications of TIPSS <ul><li>Restenosis, occlusion (rebleeding) </li></ul><ul><li>thromboembolism </li></ul><ul><li>hepatic encephalopathy (13-55%) </li></ul><ul><li>haemorrhage, haemobilia, cholangitis </li></ul><ul><li>stent migration </li></ul><ul><li>heart failure, liver failure </li></ul><ul><li>infection </li></ul>
    31. 34. Variceal Bleed Treatment Plan <ul><li>Resuscitation and early endoscopy </li></ul><ul><li>Banding +/-sclerotherapy </li></ul><ul><li>?haemostasis repeat 5-7 days </li></ul><ul><li>?failed iv vasoconstrictor +/-tamponade </li></ul><ul><li>?failed endoscopy x2/medical Rx ?TIPSS </li></ul>
    32. 35. Lower GI Bleeding <ul><li>Diverticular disease </li></ul><ul><li>Adenoma/Carcinoma </li></ul><ul><li>Colitis </li></ul><ul><li>Angiodysplasia </li></ul><ul><li>Vasculitis </li></ul><ul><li>Ischaemia </li></ul><ul><li>Haemorrhoids </li></ul>
    33. 37. Paracetamol Overdose <ul><li>15g potentially lethal </li></ul><ul><li>conjugates sulphate and glucuronide </li></ul><ul><li>toxic metabolite NAPQI binds glutathione </li></ul><ul><li>excreted as cysteine conjugate </li></ul><ul><li>N-acetyl cysteine/methionine releases glutathione </li></ul>
    34. 38. High risk paracetamol overdoses <ul><li>Pre-existing liver disease </li></ul><ul><li>high alcohol intake </li></ul><ul><li>enzyme inducing medication </li></ul>
    35. 40. Paracetamol OD Symptoms <ul><li>Usually after 24 hours </li></ul><ul><li>anorexia, nausea, vomiting </li></ul><ul><li>day 2 abdominal pain, liver tenderness </li></ul><ul><li>liver damage detectable>18 hours </li></ul><ul><li>maximal liver damage 72-96hours </li></ul>
    36. 41. Complications of Paracetamol Overdose <ul><li>Jaundice and FHF </li></ul><ul><li>renal failure (ATN) </li></ul><ul><li>hyperlactataemia (mild early, late severe) </li></ul><ul><li>metabolic acidosis </li></ul><ul><li>hypophosphataemia, hypo/hyperglycaemia </li></ul><ul><li>cardiac arrhythmias </li></ul><ul><li>pancreatitis, GI bleeding, cerebral oedema </li></ul>
    37. 42. Management of Paracetamol OD <ul><li>? level  4hours </li></ul><ul><li>lower significant level if high risk </li></ul><ul><li>? gastric lavage </li></ul><ul><li>iv n-acetyl cysteine </li></ul><ul><li>IV fluids ++ </li></ul><ul><li>Antibiotics </li></ul><ul><li>early liaison with liver unit, ? renal dialysis </li></ul><ul><li>liver transplantation </li></ul>
    38. 43. Prognostic factors <ul><li>PTT >100s (PTT >180s < 8% survival) </li></ul><ul><li>pH <7.30 (15% survival) </li></ul><ul><li>creatinine >300 (23% survival) </li></ul><ul><li>factor VIII/V close correlation prediction survival </li></ul>
    39. 45. Severe Ulcerative colitis <ul><li>Truelove and Witt’s Criteria of severity </li></ul><ul><li>bowel frequency >6/day, bloody diarrhoea </li></ul><ul><li>heart rate >90/min </li></ul><ul><li>ESR >30mm/hr </li></ul><ul><li>temperature >37.5 </li></ul><ul><li>Hb <10g/dl </li></ul>
    40. 46. Symptoms severe UC <ul><li>? systemically unwell </li></ul><ul><li>Fever </li></ul><ul><li>Abdominal pain </li></ul><ul><li>dehydration </li></ul><ul><li>electrolyte imbalance </li></ul>
    41. 49. Assessment of severe UC <ul><li>Stool cultures </li></ul><ul><li>Blood tests - FBC, U&Es, ESR, LFTs, albumin, CRP </li></ul><ul><li>AXR - toxic megacolon, mucosal islands small bowel loops </li></ul><ul><li>flexible sigmoidoscopy - severity ulceration </li></ul>
    42. 50. Management of Severe UC <ul><li>Joint physician/surgeons </li></ul><ul><li>high dose intravenous steroids </li></ul><ul><li>rectal steroid </li></ul><ul><li>ivi </li></ul><ul><li>free fluids/light diet </li></ul><ul><li>close monitoring </li></ul>
    43. 51. Course of Severe UC <ul><li>25% severe colitics considered for colectomy </li></ul><ul><li>urgent colectomy if complications </li></ul><ul><li>daily AXR if abnormal </li></ul><ul><li>regular blood tests </li></ul><ul><li>If at day 3 CRP >45 or bowel frequency >8/day & CRP <45 = 83% risk colectomy </li></ul><ul><li>?role for iv/oral cyclosporin </li></ul>
    44. 52. Crohn’s colitis <ul><li>High dose iv steroids +/- rectal steroids </li></ul><ul><li>Antibiotics - metronidazole </li></ul><ul><li>role for anti-TNF  </li></ul>
    45. 56. Liver Failure/Decompensation <ul><li>History is crucial </li></ul><ul><li>Establish Childs score </li></ul><ul><li>Ascites, Albumin, Bilirubin, PT, Encephalopathy. </li></ul><ul><li>Look for why Decompensated </li></ul>
    46. 57. Decompensation <ul><li>GI Bleed </li></ul><ul><li>Sepsis </li></ul><ul><li>Drugs </li></ul><ul><li>Constipation </li></ul><ul><li>Dehydration </li></ul><ul><li>End Stage </li></ul><ul><li>?? Head injury </li></ul>
    47. 58. Investigations <ul><li>FBC/MCV </li></ul><ul><li>Clotting </li></ul><ul><li>U+Es </li></ul><ul><li>Albumin + LFTs </li></ul><ul><li>CRP/ESR </li></ul><ul><li>AFP + USS (? PV thrombosis/hepatoma) </li></ul><ul><li>Hep screen if not previously done </li></ul>
    48. 59. Investigations <ul><li>Ascitic diagnostic tap </li></ul><ul><li>Blood Cultures </li></ul><ul><li>Urine Cultures </li></ul><ul><li>Consider OGD </li></ul>
    49. 60. Treatment <ul><li>Stop all sedating/toxic drugs </li></ul><ul><li>Laxatives </li></ul><ul><li>Antibiotics </li></ul><ul><li>Vitamin K / Thiamine/Pabrinex </li></ul><ul><li>Decide ITU/Transplant candidate </li></ul><ul><li>Consider NG tube </li></ul><ul><li>High protein / Low Salt diet </li></ul><ul><li>Avoid Saline !!!!!! </li></ul>
    50. 61. Ascites is not just a Cosmetic Problem ! <ul><li>Median Survival 2 years from onset </li></ul><ul><li>Survival depends mainly on Liver Function </li></ul><ul><li>SBP occurs ~25% </li></ul><ul><li>Low urinary Na + & SBP predict high mortality </li></ul>
    51. 62. SBP <ul><li>No Set Rules! </li></ul><ul><li>? Drain </li></ul><ul><li>3 x 100mls 20% salt poor HAS day 1+2 </li></ul><ul><li>2 x 100mls 20% HAS day 3 </li></ul><ul><li>Antibiotics long term </li></ul><ul><li>Consider transplant </li></ul>
    52. 64. Hepatorenal syndrome Splanchnic vasodilatation Effective underfilling Salt and water retention Vasoconstrictor systems Renal vasoconstriction Hepatorenal syndrome Ascites
    53. 65. Hepatorenal syndrome <ul><li>Diagnosis </li></ul><ul><ul><li>Diagnosis according to strict criteria (IAC 1996) </li></ul></ul><ul><ul><li>Renal failure in context of liver failure in absence of other cause associated with low urinary sodium </li></ul></ul><ul><ul><li>Type 1 </li></ul></ul><ul><ul><ul><li>Rapidly progressive renal failure. Median survival 15 days </li></ul></ul></ul><ul><ul><li>Type 2 </li></ul></ul><ul><ul><ul><li>Slowly progressive but patients at risk of deterioration to Type 1. </li></ul></ul></ul>
    54. 66. Treatment options <ul><li>Vasoconstrictors </li></ul><ul><ul><li>Terlipressin </li></ul></ul><ul><ul><li>Noradrenaline </li></ul></ul><ul><ul><li>Midodrine and octreotide </li></ul></ul><ul><li>Increase central blood volume </li></ul><ul><ul><li>Albumin </li></ul></ul><ul><ul><li>TIPSS </li></ul></ul><ul><li>Transplantation </li></ul>
    55. 67. Hepatorenal syndrome <ul><li>Terlipressin with albumin </li></ul><ul><ul><li>Long acting vasopressin analague, splanchnic vasoconstrictor </li></ul></ul><ul><ul><li>21 patients with Type 1 HRS </li></ul></ul><ul><ul><li>Terlipressin (0.5-2mg IV Q4hrly ) + Albumin (1g/kg then 20-30g/day) </li></ul></ul><ul><ul><li>15 days or until creatinine normal </li></ul></ul><ul><ul><li>12/21 (57%) complete response (historically 15%) </li></ul></ul><ul><ul><li>CR 77% with albumin Vs 25% if no albumin ( P<0.03 ) </li></ul></ul><ul><ul><li>17% relapsed after withdrawal drug </li></ul></ul><ul><ul><li>CR associated with increased survival Ortega, Hepatology, 2002 </li></ul></ul>
    56. 68. Hepatorenal syndrome <ul><li>Noradrenaline </li></ul><ul><ul><li>N=12 </li></ul></ul><ul><ul><li>0.5-3mg/h + albumin + frusemide </li></ul></ul><ul><ul><li>10+/-3days </li></ul></ul><ul><ul><li>Aim CrCl > 40ml/min, creatinine < 133micmol/L </li></ul></ul><ul><ul><li>Reversal 10/12 </li></ul></ul><ul><ul><ul><li>association with increase MAP, decrease renin-aldosterone </li></ul></ul></ul><ul><ul><li>3 OLT, 4 “more stable”, 5 “early deaths” </li></ul></ul><ul><ul><ul><li>Duvoux Hepatol 2002 </li></ul></ul></ul>
    57. 69. Hepatorenal syndrome <ul><li>Midodrine and octreotide </li></ul><ul><ul><ul><li>N= 13 Type 1 HRS </li></ul></ul></ul><ul><ul><ul><li>Oral midodrine (oral vasoconstrictor)+ S/C octreotide Vs M+O+DA to increase MAP >15mmHg for 20 days </li></ul></ul></ul><ul><ul><ul><li>Small study but improved survival in M+O Vs +DA Angeli 1999 </li></ul></ul></ul>
    58. 70. Hepatorenal syndrome <ul><li>TIPSS </li></ul><ul><ul><ul><li>41 non transplant candidates ( non randomised) </li></ul></ul></ul><ul><ul><ul><li>31 TIPSS (21 type 1, 10 type 2) </li></ul></ul></ul><ul><ul><ul><li>Maximal benefit takes 2 weeks </li></ul></ul></ul><ul><ul><ul><li>Increased creatinine clearance, salt excretion </li></ul></ul></ul><ul><ul><ul><li>Survival 3/12: 81% Vs 10% Brensing Gut 2000 </li></ul></ul></ul>
    59. 71. Hepatorenal Syndrome <ul><li>TIPSS </li></ul><ul><ul><li>Type 2 HRS </li></ul></ul><ul><ul><ul><li>N=18 Type 2 HRS CP C </li></ul></ul></ul><ul><ul><ul><li>No HE resistant to medical therapy </li></ul></ul></ul><ul><ul><ul><li>Complete remission of ascites </li></ul></ul></ul><ul><ul><ul><li>Improved renal function Testino, Hepatogastro 2003 </li></ul></ul></ul>
    60. 72. Hepatorenal Syndrome <ul><li>Medical therapy as a Bridge to TIPSS </li></ul><ul><ul><ul><li>N=14, Type 1 HRS, M+O 14 days </li></ul></ul></ul><ul><ul><ul><li>10/14 improved renal function and sodium handling </li></ul></ul></ul><ul><ul><ul><li>5/10 - TIPSS </li></ul></ul></ul><ul><ul><ul><ul><li>Normal renal function, Na handling and no ascites at 1 year </li></ul></ul></ul></ul><ul><li>Wong Hepatol 2004 </li></ul>
    61. 73. Hepatorenal syndrome <ul><li>Effect of HRS upon outcome of OLT </li></ul><ul><ul><li>N=9 HRS with terlipressin Rx </li></ul></ul><ul><ul><li>N=27 without HRS </li></ul></ul><ul><ul><li>Same 3 year survival </li></ul></ul><ul><ul><li>Same renal function post OLT, time in hospital and ITU post OLT </li></ul></ul><ul><ul><li>Restuccia T, J Hepatol 2004 </li></ul></ul>
    62. 74. Hepatorenal syndrome <ul><li>Summary </li></ul><ul><ul><li>Terlipressin with plasma expansion </li></ul></ul><ul><ul><li>Increasing role of TIPSS in </li></ul></ul><ul><ul><ul><li>Transplant candidates </li></ul></ul></ul><ul><ul><ul><li>Type 2 HRS </li></ul></ul></ul><ul><ul><ul><li>Medical therapy as bridge to TIPSS/ OLT </li></ul></ul></ul><ul><ul><li>Consider transplantation </li></ul></ul>
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