DRILL = Chronic liver disease history
- Diagnosis and presentation
- Underlying cause / RFs
- Course
○ Frequency of hospital admits
○ Triggers for decompensation - Current status / symptoms
- Cx and Mx of each
○ Fluid overload / ascites
○ Encephalopathy
○ HRS
○ Varices
○ HCC
○ Psychosocial IMPACT - Monitoring
- Future -> transplant
DRILL = Haemachromatosis Hx
- Diagnosis + presentation
- RFs -> FHx
- Course / Admissions
- Management overall
○ Diet
○ Pharm -> chelation
○ Phlebotomy - Manifestations + Mx of each :
○ Liver
○ Joints
○ Heart
○ Pancreas
○ Gonads - Current status and functional IMPACT
- Monitoring
- Future plans
How would you evaluate for pancreatic insufficiency?
I would be concerned about this in a patient with CF, chronic pancreatitis or previous surgery.
Symptoms: steatorrhea, weight loss
Ix: faecal elastase (low), fat soluble vitamins
Mx: Dietician, Creon
When would you treat a patient with Chronic Hep B with anti-virals?
I would be treating them in certain situations where benefit has been shown
- in patients with cirrhosis or advanced fibrosis to reduce progression to HCC
- in those with a high ALT or viral load
- in those at particularly high risk of HCC due to PHx or FHx
How would you monitor and manage this person’s cirrhosis?
At each review:
- Clinical assessment of fluid status, encephalopathy, nutrition
- Biochemistry:
○ Synthetic function (Albumin, INR) + LFTs, BIli
○ FBE (platelets)
○ UEC for renal fx and electrolytes
- Imaging
○ USS + AFP 6 monthly for HCC
○ Gastroscopy 1-2 yearly for varices
○ Bone health with DEXA
Recommendations:
- Lifestyle -> HEHP diet, evening snack. Salt restriction. Nutrition input
- Specific Mx of each Cx
- Regular monitoring and follow up
- Plan for liver transplant if appropriate
How would you manage this person’s NAFLD?
Lifestyle modification is the cornerstone of management
- Diet -> even 5% weight loss will improve liver architecture. This should be done slowly - Exercise - Behavioural change with psychologist to assist in sustainable weight loss and lifestyle changes - Monitor glucose + lipids regularly + manage accordingly to target - Consider Vitamin E supplementation in nondiabetic patients
What are the tests to diagnose Wilson’s Disease?
- caeruloplasmin (low)
- 24 hr urinary copper (high)
- serum copper (low)
- liver biopsy
What are the clinical manifestations of Wilson’s Disease?
- Liver dysfunction
- Neuropsychiatric features / ocular
- Arthropathy
How would you manage this person with Wilson’s Disease?
- In conjunction with a Gastro Specialist
- Genetic counselling
- Low copper diet
- Chelating agents
- Treat complications
- Consider for liver transplant
How would you manage this person with Haemachromatosis?
- Genetic counselling
- Lifestyle
○ Minimise ETOH
○ Avoid iron / Vit C supplements - Pharm
○ Chelating agents - Procedure
○ Venesection, aiming ferritin <50 - Treat specific complications
- Lifestyle
How would you investigate diarrhoea?
• Infective ○ Stool MCS + OCP ○ C.diff toxin if relevant, can check AXR for toxic megacolon • Malabsorptive ○ Faecal elastase ○ Coeliac serology ○ Fat soluble vitamins / iron ○ TFT • Inflammatory ○ Faecal calprotectin (high) • Ischaemic ○ CT Abdo / Angio • Malignant ○ CT ○ C'scope + biopsy
How would you manage this person’s IBS?
- Important to develop therapeutic relationship with the patient and give reassurance
- Exclude red flag conditions
- Lifestyle measures are the cornerstone
○ Detailed assessment with an experienced dietician and keeping diary to assess for triggers
○ Consider low FODMAP diet / exclusion of triggers
○ Slow increase in fibre intake
○ Psychological support + CBT. Consider antidepressant therapy (fluoxetine)
DRILL = IBD Hx
- Diagnosis + presentation
- RFs:
○ FHx
○ PSC, other auto-immune conditions
○ ?Smoking - Course
○ Flares / exacerbations / admissions - Management
- Complications + Mx
○ Strictures
○ Fistulas
○ Extra-intestinal (joints, skin, eyes, liver, VTE)
○ Psychosocial IMPACT - Current symptoms / activity
- Monitoring
- CRC surveillance
- RFs:
How would you monitor Methotrexate?
- LFTs + Renal function every 1-2 months
- FBE for macrocytic anaemia risk
- Monitor for resp symptoms / changes in lung function
How will you assess activity in IBD?
- Clinically ○ Symptoms (bowels) ○ Systemic illness (fever, weight loss, anaemia) ○ Extra-intestinal § Large joint arthritis § Episcleritis § Erythema nodosum § Sweet Syndrome - Biochemically ○ CRP ○ Faecal calprotectin - Imaging ○ Intestinal USS ○ Scope
What classifies as ‘decompensated’ cirrhosis?
Development of complications such as:
- variceal hemorrhage
- ascites / SBP
- HCC
- HRS
- hepatopulmonary syndrome
What are decompensating events in cirrhosis?
- Infections including SBP
- HCC
- variceal bleeding
- sedative medications
- electrolyte disturbance (K, Na)
What components factor into Child Pugh scoring? What is significance of this?
Albumin Bilirubin Coagulopathy -> INR Distension (ascites) Encephalopathy
Predictor of mortality -> CP-C 33% 1 year mortality
Is there any way for you to slow progression of this person’s liver disease?
Can treat viral hepatitis
- slows progression of fibrosis
Can prevent superimposed insults
- ETOH abstinence
- healthy weight + nutrition
- infection prevention strategies
Early identification of complications
- timely screening / regular review
What are some causes of non-cirrhotic portal HTN?
Portal vein thrombosis Budd-Chiari Syndrome Cardiac -> constrictive / restrictive Idiopathic Schistosomiasis
