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