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  <head>
    <title>048-01 Foundations</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Liver, biliary tract, and pancreatic disease">
      <outline text="Orientation and liver tests">
        <outline text="Portal blood brings nutrients, toxins, microbial products"/>
        <outline text="Hepatocytes synthesise, detoxify, make urea and bile"/>
        <outline text="Symptoms subtle until reserve is exhausted"/>
        <outline text="Aminotransferases mark membrane injury, not function"/>
        <outline text="Alkaline phosphatase: cholestasis, also bone"/>
        <outline text="Albumin reflects weeks, altered by many factors"/>
        <outline text="Prothrombin time changes rapidly with synthetic failure"/>
      </outline>
      <outline text="Pattern and investigation">
        <outline text="Hepatocellular pattern: aminotransferases dominate"/>
        <outline text="Cholestatic pattern: phosphatase and bilirubin"/>
        <outline text="Very high values: ischaemia, paracetamol, hepatitis">
          <outline text="Degree does not reliably predict outcome"/>
        </outline>
        <outline text="Ultrasound: ducts, gallbladder, texture, vessels, ascites"/>
      </outline>
      <outline text="Jaundice">
        <outline text="Unconjugated: haemolysis, ineffective erythropoiesis"/>
        <outline text="Conjugated bilirubin is water soluble, darkens urine"/>
        <outline text="Pale stool and pruritus: less bile reaches gut"/>
        <outline text="Painful febrile jaundice: ascending cholangitis"/>
        <outline text="Painless progressive jaundice: malignant obstruction"/>
        <outline text="Urgent if coagulopathy, confusion, hypoglycaemia"/>
      </outline>
      <outline text="Acute hepatitis and liver failure">
        <outline text="Viral, drug, toxic, immune, ischaemic, metabolic causes"/>
        <outline text="Precise exposure timeline including herbal products">
          <outline text="Dose and timing crucial in paracetamol poisoning"/>
        </outline>
        <outline text="Failure: new injury, coagulopathy, encephalopathy"/>
        <outline text="Cerebral oedema, hypoglycaemia, infection, collapse"/>
        <outline text="Repeat glucose, stop toxins, avoid sedation"/>
        <outline text="Early discussion with a transplant centre"/>
        <outline text="N-acetylcysteine replenishes glutathione"/>
      </outline>
      <outline text="Chronic liver disease and cirrhosis">
        <outline text="Nodules and scar raise intrahepatic resistance">
          <outline text="Function falls"/>
        </outline>
        <outline text="Compensated disease may be silent"/>
        <outline text="Decompensation: ascites, bleeding, encephalopathy"/>
        <outline text="Alcohol: steatosis to hepatitis to cirrhosis">
          <outline text="Abstinence support is central"/>
        </outline>
        <outline text="Metabolic steatotic disease: insulin resistance">
          <outline text="Fibrosis stage predicts liver outcomes"/>
        </outline>
        <outline text="Hepatitis B integrates, cancer without cirrhosis"/>
        <outline text="Hepatitis C cured, advanced fibrosis still monitored"/>
      </outline>
      <outline text="Portal hypertension and ascites">
        <outline text="Collaterals, splenomegaly, ascites"/>
        <outline text="Varices may bleed catastrophically">
          <outline text="Beta blockade or banding for prevention"/>
        </outline>
        <outline text="Acute bleeding: restrained resuscitation">
          <outline text="Vasoactives, antibiotics, endoscopic control"/>
          <outline text="Shunt if bleeding persists or high risk"/>
        </outline>
        <outline text="Ascites: portal pressure, vasodilation, sodium retention"/>
        <outline text="Diagnostic paracentesis for new or worsening ascites"/>
        <outline text="Peritonitis may lack local tenderness">
          <outline text="Prompt antibiotics, albumin in selected patients"/>
        </outline>
        <outline text="Recurrent ascites: sodium, diuretics, drainage">
          <outline text="Albumin replacement with large volumes"/>
        </outline>
      </outline>
      <outline text="Encephalopathy and hepatorenal dysfunction">
        <outline text="Altered attention, sleep, behaviour, consciousness"/>
        <outline text="Lactulose promotes colonic ammonia disposal">
          <outline text="Titrate to regular soft stool"/>
        </outline>
        <outline text="Rifaximin reduces recurrence"/>
        <outline text="Ammonia level neither confirms nor excludes"/>
        <outline text="Kidney injury: volume, sepsis, nephrotoxins first"/>
        <outline text="Hepatorenal: renal vasoconstriction amid vasodilation">
          <outline text="Albumin plus vasoconstrictor bridges to transplant"/>
        </outline>
      </outline>
      <outline text="Liver cancer and transplantation">
        <outline text="Cirrhosis and hepatitis B raise carcinoma risk"/>
        <outline text="Surveillance finds tumours for curative therapy"/>
        <outline text="Alpha-fetoprotein supports, not diagnostic alone"/>
        <outline text="Transplant replaces function, removes portal hypertension">
          <outline text="Lifelong immune suppression and surveillance"/>
        </outline>
      </outline>
      <outline text="Gallstones and biliary disease">
        <outline text="Supersaturated bile and gallbladder stasis"/>
        <outline text="Biliary pain: transient cystic-duct obstruction"/>
        <outline text="Cholecystitis: prolonged pain, fever, tenderness">
          <outline text="Ultrasound first, early cholecystectomy"/>
        </outline>
        <outline text="Common-duct stone: jaundice or pancreatitis"/>
        <outline text="Cholangitis is infected obstruction">
          <outline text="Fluids, antibiotics, urgent drainage"/>
        </outline>
      </outline>
      <outline text="Pancreatitis and pancreatic cancer">
        <outline text="Acute: premature enzyme activation">
          <outline text="Gallstones and alcohol are common causes"/>
        </outline>
        <outline text="Severity: organ failure, not enzyme height"/>
        <outline text="Analgesia, titrated fluids, enteral nutrition"/>
        <outline text="Prophylactic antibiotics do not treat sterile necrosis"/>
        <outline text="Chronic: irreversible fibrosis">
          <outline text="Exocrine failure, diabetes, cancer risk"/>
          <outline text="Enzymes with meals, vitamins, diabetes care"/>
        </outline>
        <outline text="Cancer presents late, often painless jaundice">
          <outline text="Imaging establishes resectability"/>
          <outline text="Surgery with systemic therapy: main chance of cure"/>
        </outline>
      </outline>
    </outline>
  </body>
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