--- module: 048-02 language: en chapter: 48 title: "Liver, Biliary Tract, and Pancreatic Disease" module_title: "Hepatic reserve, portal failure, biliary sepsis, and pancreatic systemic injury" source_sha256: f9757a3aba68a4c9161b48cc58ab8fc06684b7edf3e52d1aa9fe445fc097a947 --- # Hepatic reserve, portal failure, biliary sepsis, pancreas ## Three axes of liver tests ### Injury, bile flow, functional reserve ### Aminotransferases leak from injured cells #### Fall with recovery or with few hepatocytes left ### Prothrombin time fast, albumin slow ### Pattern: aminotransferase versus phosphatase ratio #### Hepatocellular: viral, toxic, immune, ischaemic #### Cholestatic: obstruction, infiltration, small ducts ### Modest values can accompany advanced cirrhosis ## Jaundice and drug-induced injury ### Localise jaundice before imaging ### Conjugated bilirubin: excretory failure or obstruction ### Painful febrile jaundice: infected obstruction ### Painless jaundice: pancreatic, biliary, hepatic cancer ### Complete exposure timeline with re-exposure ### Predictable dose-related versus idiosyncratic delayed ### Rechallenge can provoke more severe injury ## Acute liver failure ### Danger extends beyond bleeding #### Cerebral oedema, hypoglycaemia, shock, kidney injury ### Serial glucose, neurology, acid-base in intensive care ### Sedatives cloud encephalopathy assessment ### Prompt N-acetylcysteine if paracetamol suspected #### Unknown timing does not exclude paracetamol ### Seek causes in parallel, do not delay referral ### Prophylactic plasma obscures risk and transplant decision ## Cirrhotic circulation and haemostasis ### Septa and nodules raise sinusoidal resistance ### Splanchnic vasodilation lowers effective volume #### Kidneys perceive underfilling, retain sodium ### Collaterals bypass clearance, form varices ### Splenic congestion lowers platelets ### Fragile rebalanced haemostasis #### Tests miss loss of anticoagulant factors ## Ascites and peritonitis ### Sample when new, worsening, or admitted ### Blood-culture bottles improve culture yield ### Albumin gradient estimates portal cause ### Normal white count or no fever does not exclude ### Routine coagulopathy does not delay diagnosis ### Treat at neutrophil threshold before cultures ### Polymicrobial or localised signs: secondary peritonitis ### Diuretics balance retention against effective volume #### Overdiuresis: kidney injury, hyponatraemia ### Large-volume drainage needs albumin replacement ## Variceal bleeding ### Avoid excess volume that raises portal pressure ### Protect airway, vasoactives, antibiotics, ligation ### Tamponade is a temporary bridge ### Early shunt helps high risk, worsens encephalopathy ### Secondary prevention: beta blocker plus ligation ### Look for coexisting lesions such as ulcer ## Encephalopathy and kidney injury ### Ammonia correlates poorly with the syndrome ### Search bleeding, infection, diuresis, sedatives ### Lactulose traps nitrogen in the colon ### Kidney injury is not automatically hepatorenal #### Volume loss, sepsis, nephrotoxins assessed first ### Hepatorenal: vasodilation plus renal vasoconstriction #### Albumin challenge supports diagnosis ### Urinary sodium alone misleads ### Monitor ischaemia during vasoconstrictor therapy ## Steatotic and biliary disease ### Steatotic disease part of insulin resistance #### Fibrosis stage outweighs steatosis ### Non-invasive scores avoid biopsying everyone ### Biliary pain steady, not truly colicky ### Cholangitis is sepsis behind an obstructed duct #### Antibiotics cannot sterilise without drainage ## Acute pancreatitis ### Enzyme activation, then vascular leak ### Compatible combination, not all three findings ### Enzyme height does not grade severity ### Persistent organ failure predicts severe disease ### Titrated crystalloid, not aggressive fluid #### Excess worsens lung and abdominal oedema ### Early enteral nutrition preserves gut integrity ### Delay intervention, step-up approach ### Urgent cholangiopancreatography: cholangitis, obstruction ## Chronic pancreatitis, cancer, and synthesis ### Exocrine and endocrine destruction #### Low glucagon reserve: hypoglycaemia risk ### Enzymes in lipase units from first mouthful ### Pain care beyond opioids alone ### Cancer presents through obstruction, not mass #### Coordinate so procedures do not delay surgery ### Improving tests are not recovery ### Name owner and time of reassessment