HEPATOLOGY

Take a focused history of the patient covering presenting complaint, past medical history, drug history, social history and family history. If appropriate, perform a focused abdominal examination.

Consider:

• What differential diagnoses have you considered?
• What investigations would be useful in this case?

Consider the term 'decompensated chronic liver disease'. Write down a definition.

For the patient you have seen, consider the following:

1. What are the causes of chronic liver disease - what tests may be useful to determine the underlying cause? What comprises a non-invasive liver screen?
2. What are the causes of acute decompensation - what tests might be useful to determine the cause of decompensation?

Find some relevant clinical guidelines for the management of decompensated chronic liver disease. These may be trust guidelines or national BASL guidelines.

Find a drug chart and practise prescribing the following medications:

• Lactulose
• Pabrinex
• Appropriate alcohol withdrawal regimen e.g. PRN chlordiazepoxide
• Human albumin solution
• Antibiotics for suspected spontaneous bacterial peritonitis
• Vitamin K for coagulopathy

If possible, ask to observe diagnostic or abdominal paracentesis. Whilst preparing for this procedure, or if it is not possible to view one on the ward, consider the following questions:

• What are the risks of the procedure?
• What anatomical structures are relevant to be aware of during the procedure?
• What tests can be performed on ascitic fluid?

If possible, practice taking verbal or written consent from a colleague.

Consider the key symptoms and signs of significant variceal bleeding vs. non-variceal bleeding.

Suggest the key features of initial management, for example:

• A to E assessment
• When might it be appropriate to initiate the major haemorrhage protocol?
• What is the mechanism of action of terlipressin? When is it indicated? What are the main risks of its use?
• What is the role of endoscopy? When should endoscopy take place?
• What other interventions are there? Consider Sengstaken-Blakemore tubes. When might it be appropriate to use them?

Highlight three key things you have learned today. Summarise them on a post-it note and keep it somewhere you will find in a week or two.

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