GIT Dr.

Shaf3y

G.I.T. 2013 15 50 Liver function of the liver

alpha feto protein

liver biopsy

MCQ Liver function test liver function test alpha feto protein Liver biopsy MCQ

manifestations of chronic liver cell failure

Manifestations of chronic liver cell failure

chronic liver disease disease Chronic liver disease chronic liver cell failure Liver disease chronic liver cell failure chronic liver cell failure cirrhosis

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GIT Dr. Shaf3y

auto immune hepatitis 6 chronic liver disease Liver Liver

C.N.S. liver C.N.S. manifestations of liver cell failure hepatic encephalopathy

Hepatic encephalopathy
hepatic encephalopathy treatment Investigations clinical pictures etiology definition

definition of hepatic encephalopathy definition of hepatic encephalopathy It is a neuropsychiatric manifestations It is a neuropsychiatric manifestations due to liver cell failure Neuropsychiatric manifestations due to liver cell failure definition etiology neuropsychiatric manifestations Hepatic encephalopathy toxins Liver theory Colon

Liver

Portal vein Liver Liver inferior vena cava

toxins toxins

toxins

Normal

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GIT Dr. Shaf3y

colon toxins proteins Portal veins toxins toxins toxins Liver Liver Liver

Liver cell failure toxins liver toxins blood stream toxins Liver toxins brain

theory Liver cell failure colon toxins Liver toxins blood stream toxins Liver toxins brain Liver

porto-systemic shunts

liver cell failure Portal hypertension Portal hypertension Porto-systemic shunt

Liver

brain
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bypass colon toxins inferior vena cava Portal vein Liver bypassing inferior vena cava

GIT Dr. Shaf3y

blood stream toxins Portal hypertension encephalopathy

bilharziasis cirrhosis cirrhosis bilharziasis periportal fibrosis Portal hypertension bilharziasis

Hepatic encephalopathy liver cell failure

bilharziasis Portal hypertension collaterals liver bypass toxins inferior vena cava

liver cell failure

bilharziasis Hepatic encephalopathy

cirrhosis

bilharziasis

hepatic encephalopathy

brain suppression

brain brain

colon colon

toxins toxins

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GIT Dr. Shaf3y

theories toxins

ammonia ammonia << liver ammonia urea ammonia Urea

Liver Urea Kidney

colon Urea urine ammonia Liver ammonia Urea Kidney

Urea renal failure

Liver cell failure Urea Liver cell failure by the way

renal failure

Urea Liver cell failure

40 Normal 15 << Liver cell failure

Urea

renal failure 40 Urea renal failure

Liver cell failure

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GIT Dr. Shaf3y

ammonia theory ammonia liver Liver cell failure ammonia Liver

suppression brain ammonia brain suppression ammonia Krebs cycle inhibition ammonia glucose metabolism Krebs cycle krebs cycle brain suppression metabolism ammonia

theory Hepatic encephalopathy theory theory theory theory ammonia coma hepatic encephalopathy ammonia theory brain convulsions

ammonia convulsions

coma coma Hepatic encephalopathy convulsions

ammonia at least

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GIT Dr. Shaf3y

disturbed conscious level ammonia Hepatic encephalopathy convulsions

ammonia

methyl mercaptans

Liver Methyl mercaptans methyl mercaptans Liver Methyl mercaptans Liver methyl mercaptan Methyl mercaptan brain ammonia

brain

ammonia

ammonia

branched chains amino acids branches chains amino acids amino acids aromatic amino acids branched chains amino acids

branched chain amino acids brain adrenaline dopamine brain stimulation

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GIT Dr. Shaf3y

aromatic amino acids octopamine brain inhibition

balance inhibition stimulation

Branched chains amino acids aromatic mediators balance

liver cell failure Liver cell failure branched chain amino acids

glycogen

liver

Liver cell failure

gluconeogenesis amino acids glucose amino acids branched chain Liver cell failure branched chain branched chains upper hand aromatic aromatic Inhibition hepatic encephalopathy theory
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gluconeogenesis

brain

GIT Dr. Shaf3y

Benzodiazepine like material benzodiazepine like material ICU ICU Benzodiazepine inhaled injected theory

injected

inhaled inhaled anesthesia mask effect

injection anesthesia antidote morphine dose

effect

naloxone

immediately antidote immediately

Naloxone

inhalation anesthesia 6 Half life

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GIT Dr. Shaf3y

combination anesthesia

injection anesthesia

by injection anesthesia antidote

team

antidote

ICU delayed recovery ICU antidote

antidote

Hernia

Liver cell failure

delayed recovery ICU hepatic encephalopathy ICU antidote

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GIT Dr. Shaf3y

antidote injection ICU inhalation This is what happened exactly by chance antibiotics fungus fungus

fungus

by chance Just by chance

antidote

inhalation

inhalation

by injection antidote flumazinel Flumazinel Benzodiazepine antagonist

hepatic encephalopathy Flumazinel Benzodiazepine antagonist

Benzodiazepine like material

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GIT Dr. Shaf3y

brain action Benzodiazepine like material brain cells chloride hepatic encephalopathy

theory Hypokalemia

diuretics

liver cell failure ascites tapping encephalopathy

Injection of diuretics tapping hypokalemia hypokalemia encephalopathy

encephalopathy

diuretics paracentesis

hypokalemia paracentesis hepatic encephalopathy

diuretics Hypokalemia

encephalopathy

Hypokalemia

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GIT Dr. Shaf3y

shift

Positive positive ammonia

according to concentration gradient Positive positive

ammonia

brain cells

shift << ammonia Hypokalemia ammonia encephalopathy alkalosis severe vomiting encephalopathy alkalosis alkalosis vomiting alkalosis

hepatic encephalopathy

positive ammonia

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GIT Dr. Shaf3y

hepatic encephalopathy theories

Liver cell failure hepatic encephalopathy encephalopathy hepatic encephalopathy Liver cell failure Precipitating factors hepatic encephalopathy

Hepatic encephalopathy

hepatic encephalopathy

Precipitating factors Precipitating factors Precipitating factors sepsis Over growth of bacteria heavy protein meals Heavy protein meals

hematemesis

G.I.T.

hematemesis is a heavy protein meal

porto-systemic shunt Porto-systemic shunt surgery has been obsolete encephalopathy

Benzodiazepine Liver cell failure stored blood ammonia fresh blood

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GIT Dr. Shaf3y

paracentesis extensive diuretics hypokalemia vomiting Liver cell failure factors

hepatic encephalopathy encephalopathy

stage

clinical pictures hepatic encephalopathy Pre coma Coma Pre coma Pre coma

hepatic encephalopathy

Apathy, mentally dull disoriented for time, place and persons

You are not normal You have to believe in this

Psychotic

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GIT Dr. Shaf3y

No comment

Hepatic encephalopathy two stages Pre coma stage Pre coma amnesia for time, place and persons flapping tremors asterixis apathy disturbed sleeping rhythm disturbed sleeping rhythm childish behavior childish behavior Sudden laugh to sudden cry

childish behavior construction apraxia construction apraxia Pre coma He cannot copy a complex design
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GIT Dr. Shaf3y

test Pre coma

defecate

construction apraxia Loss of personal hygiene Loss of personal hygiene loss of personal hygiene urinate Urinate concept

social hygiene

Pre coma coma character Positive Babinski Positive Babinski coma stages of coma

coma

stage two

stage one

stage

stage

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GIT Dr. Shaf3y

Investigations comatosed

comatosed Hepatic encephalopathy

Hypoglycemia

hypoglycemia Liver cell failure

sub dural hematoma bleeding tendency hemorrhage Minor trauma Hemorrhage minor trauma

Which means Liver cirrhosis coma hepatic encephalopathy Which means coma cirrhosis Investigations blood glucose serum ammonia to exclude sub dural hematoma << CT brain

hepatic encephalopathy comatosed

comatosed cirrhosis

liver cirrhosis

hepatic encephalopathy
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GIT Dr. Shaf3y

circumstances treatment How to manage this patient elements

38

elements

colon toxins

Oral antibiotics Oral antibiotics

Oral antibiotics Neomycin

absorption

G.I.T. Locally << G.I.T.

neomycin orally stool absorption

systemic side effects

absorption renal failure side effects absorption

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oral neomycin

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GIT Dr. Shaf3y

absorption renal failure Has been replaced nowadays << Neomycin flagyl antibiotics Neomycin

Oral antibiotics

oral bacteria Orally << bacteria lacto-bacillus colon occupation colon proliferation colon colon lacto-bacillus orally colon proliferate suppress

diet Liver cell failure Low protein in diet

low protein in diet

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GIT Dr. Shaf3y

80 40

40

80 40

diet hematemesis Liver cell failure ryle liver cell failure hematemesis wash ryle G.I.T. G.I.T.

encephalopathy

blood G.I.T.

wash From the G.I.T.

ryle gastric lavage ) gastric wash

hematemesis

diet gastric wash

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GIT Dr. Shaf3y

Colonic Enema wash enema

Enema enema

rectum by gravity rectum

flat

enema rectum rectum wash

wash colon

Position

position

pelvis Pelvis enema

rectum colon

gravity

flat
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GIT Dr. Shaf3y

proper enema enema Enema Enema

flat

enema

Nurse

lactulose lactulose Duflak lactulose Duflak

G.I.T.

lactulose lactulose Lactose Lactic acid lactulose G.I.T. Lactose and lactic acid Lactose

intestine

Lumen diarrhea wash diarrhea

lactulose Lactose and lactic acid

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GIT Dr. Shaf3y

lactose Lumen of the intestine diarrhea wash lactic acid lactic acid colon colon inhibition lactic acid lactic acid lactic acid digestive enzymes inhibition

diarrhea

digestive enzymes digestion

wash

lactic acid colon ammonia ammonia

ammonium absorption

ammonia ammonium stool

ammonia ammonium hydrogen absorption ammonium stool

stool

colon colon

ammonia ammonia ammonia

colon
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Portal vein

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GIT Dr. Shaf3y

Portal vein colon back diffusion G.I.T. dialysis

lactose

lactulose lactic acid lactose Osmotic diarrhea lactic acid hydrogen lactic acid

diarrhea

growth of bacteria inhibition digestive enzymes Inhibition ammonium

ammonia absorption back diffusion of the ammonia to the G.I.T. Hepatic encephalopathy lactulose

bacillus lactic acid lactulose Lacto-bacillus

toxins toxins ammonia Liver cell failure Avoid transfusion of stored blood ammonia Hepamerz

urea L-arnithine
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GIT Dr. Shaf3y

Urea ammonia

Urea renal failure

ammonia

Urea ammonia ammonia

toxins mercaptan

branched chain amino acids

branched chains amino acids branched chains amino acids branched chain branched chains adrenaline dopamine brain stimulation branched chain dopamine G.I.T. << Oral << dopamine L dopa

dopamine agonist dopamine receptors

theory benzodiazepine Benzodiazepine antagonist Benzodiazepine antagonist

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GIT Dr. Shaf3y

Benzodiazepine antagonist Flumazinel

papers search source

text text papers 7 just enter paper

papers

70

Papers 15 230

70 70

papers Papers

Paper paper

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GIT Dr. Shaf3y

Unlimited number papers specialty Unlimited

100 staff

demands

ICU

coma

coma

ICU

hepatic encephalopathy
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GIT Dr. Shaf3y

papers flumazinel

papers Papers Flumazinel

benzodiazepine antagonist

hepatic encephalopathy

900 Flumazinel 3

flumazinel

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GIT Dr. Shaf3y

1/3

Flumazinel

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GIT Dr. Shaf3y

effect coma infusion convulsions Infusion convulsions Infusion convulsions

Convulsion

infusion

convulsions

infusion action

Hepatic encephalophathy

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GIT Dr. Shaf3y

5,000 5,000

5,000

papers

target target

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GIT Dr. Shaf3y

flmazinel Benzodiazipine antagonist

alkalosis

comatosed Supportive treatment Liver transplantation coma coma supportive treatment enema Liver transplant

liver transplantation liver transplantation Liver transplantation Artificial liver

waiting list

artificial liver artificial liver artificial biological liver artificial biological liver hepatocytes wall Lumen

hepatocyte

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GIT Dr. Shaf3y

toxins

hepatocyte

artificial liver Hepatocytes artificial biological liver artificial lung ventilator tissue artificial lung tissue artificial kidney dialysis

artificial artificial biological liver liver transplantation

Hepatic encephalopathy 100 G.I.T. Liver cell failure

Manifestations of liver cell failure 100 Long case

30
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G.I.T.

34

GIT Dr. Shaf3y

manifestations of liver cell failure 100 Manifestation of liver cell failure

C.N.S. C.N.S. fever fever fever Liver cell failure Liver cell failure bacteremia

Liver systemic circulation Liver Liver

Intestine portal vein Liver Liver inferior vena cava Liver

Liver bacteremia Low grade fever

Liver

disease Liver

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GIT Dr. Shaf3y

Pyrogen Pyrogen fever eye liver cell failure eye liver Liver

system eye lid eye lid cirrhosis generalized edema

eye lid

Xanthelasma Edema

eye lid conjunctiva Sub conjunctival hemorrhages bleeding tendcy cornea Kayser Fleischer ring << cornea Wilson disease Kayser Fleischer ring wilson disease

Pallor

jaundice Jaundice and pallor

eye eye fever

Foetor hepaticus Foetor hepaticus

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GIT Dr. Shaf3y

methyl mercaptan Liver methyl mercaptan Liver methyl mercaptan

saliva fletus

Methyl mercaptan

Methyl mercaptan Liver blood stream methyl mercaptan fletus saliva Liver

liver cell failure constipation pass fletus

Foetor hepaticus Rotten apple

Noway

rotten apple fecal

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English fecal sweetish fecal odor

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GIT Dr. Shaf3y

English definition

Bleeding gum

Red glazed tongue iron deficiency

Low immunity

Pallor Candida infection in oral cavity

neck neck liver cell failure Congested neck veins

Right sided heart failure right sided heart failure right sided heart failure congestive cirrhosis

congested neck veins

congested neck veins Liver cell failure congestive cirrhosis

diaphragm

raise ascites intra thoracic pressure venous return congested neck veins

Liver

heart

diseases At the same time

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GIT Dr. Shaf3y

Liver cell failure heart failure At the same time haemochromatosis amyloidosis congested neck veins heart failure cirrhosis congested neck veins At the same time

copula of the diaphragm raise ascites Intra thoracic pressure venous return

liver

diseases At the same time heart failure cirrhosis congested neck veins diseases haemochromatosis

heart

amyloidosis

alcoholism

Liver cell failure neck prominent carotid pulsation

hyper dynamic circulation

Liver cell failure goiter

neck

auto immune hepatitis

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goiter goiter

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GIT Dr. Shaf3y

auto immune thyroiditis liver cell failure neck Virchow lymph node

complicated by hepatocellular carcinoma Left supra clavicular lymph nodes enlargement

chest

chest two fallopian tube

chest uterus Lung heart heart Liver

vasodilator material estrogen prostaglandin

Liver

liver cell failure

nitric oxide << vasodilator material vasodilators material Liver Liver vasodilator materials hyper dynamic circulation Hyper dynamic circulation water hammer pulse palpitation tachycardia

heart right sided heart failure congested cirrhosis alcoholism amyloidosis hemochromatosis Liver heart At the same time

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GIT Dr. Shaf3y

heart

Liver hyper dynamic circulation

Heart heart tachycardia

functional murmur

Heart functional murmurs Hyper dynamic

heart

Liver

diseases At the same time

right sided heart failure congestive cirrhosis

liver cell failure liver cell failure

Heart lung Central cyanosis

central cyanosis

liver cell failure central cyanosis

elements of respiration

chest

muscle

atrophy

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GIT Dr. Shaf3y

Liver cell failure amino acids Muscles gluconeogenesis muscle atrophy

liver cell failure glycogen glucose amino acids Muscles wasting muscle atrophy

Pleural effusion cyanosis

Movement of diaphragm

ascites restriction

Prostaglandins

Liver vasodilator materials nitric oxide estrogen vasodilators material alveoli capillaries arteries vasodilator materials arteries shunt vein artery oxygenation

veins

veins

what we call Intra pulmonary shunt pulmonary arterio venous shunt

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GIT Dr. Shaf3y

vein artery Oxygenation hepato-pulmonary syndrome hepato-pulmonary syndrome shunt hepato-pulmonary syndrome

interstitial lung fibrosis primary biliary cirrhosis Liver cirrhosis primary biliary cirrhosis Interstitial lung fibrosis auto immune

liver cell failure

abdomen abdomen abdomen

abdomen

Organs Liver Liver Liver

shrunken

congested enlarged Liver cell failure

tender enlarged amyloidosis

shrunken liver

spleen Splenomegaly

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GIT Dr. Shaf3y

Portal hypertension immune system activation liver cell failure bacteremia immunological activation portal hypertension splenomegaly hyper splenism pan cytopenia

bacteremia

spleen

liver

abdomen Ascites ascites

Liver cell failure

mechanism of ascites ascites ascites Change in Starling forces

mechanism

Liver cell failure Liver cell failure

change in Starling forces two forces blood vessel hydrostatic fluid force osmotic fluid force Plasma proteins osmotic Starling forces Starling Starling law Starling forces

Osmotic pressure

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GIT Dr. Shaf3y

Osmotic pressure albumin

albumin blood volume

blood volume Kidney renin angiotensin aldosterone salt and water retention edema Liver aldosterone

albumin blood volume anti diuretic hormone water retention anti diuretic hormone Liver anti diuretic hormone Liver

retention

Aldosterone anti diuretic hormone retention aldosterone

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GIT Dr. Shaf3y

dilutional hyponateremia

liver cirrhosis Liver fibrosis Lymphatic fibrosis Lymphatic Liver surface liver cirrhosis Liver

cirrhosis

cirrhosis Liver liver liver cirrhosis

Pus Healing of wound

wound pus Pus

heal wound

infection pus

Liver cell failure

ascites

factor Portal hypertension Portal hypertension ascites

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GIT Dr. Shaf3y

ascites Portal hypertension portal vein Pressure

Interstitial tissue Pressure Portal hypertension 15 force

portal Pressure Interstitial tissue Portal hypertension Portal hypertension Just localizing factor localizing factor Hypoalbuminemia at the same time albumin at the same time ascites ascites Liver edema abdomen abdomen portal hypertension ascites

Lower limb edema

Localizing factor heart edema

Lower limbs

veins congested right sided heart failure congested dependant

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veins veins

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GIT Dr. Shaf3y

eye lid edema Nephrotic

localizing factor

Mechanism Starling forces disturbance Hydrostatic pressure osmotic pressure osmotic pressure albumin Hydrostatic salt and water retention portal hypertension Lymphatic obstruction Liver cell failure ascites ascites malignancy Hepatocellular carcinoma Liver cirrhosis hepatocellular carcinoma ascites ascites T.B. peritonitis Liver cirrhosis immunity T.B. peritonitis liver cell failure ascites

spontaneous bacterial peritonitis

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GIT Dr. Shaf3y

spontaneous bacterial peritonitis E.Coli colon colon wall E.Coli peritoneum

peritoneum E.Coli immune system E.Coli peritoneum Immune system Liver cell failure He is immunocompromized immune system peritoneum E.Coli peritoneum infection spontaneous bacterial peritonitis spontaneous bacterial peritonitis Occurs due to translocation of E.Coli from the colon to the peritoneum Leading to peritonitis due to defective immune clearance of this E.Coli

spontaneous bacterial peritonitis rigidity tenderness

clinical pictures clinical pictures abdominal pain Fever ascites hepatic encephalopathy precipitate sepsis

spontaneous bacterial peritonitis encephalopathy

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GIT Dr. Shaf3y

Hepato-renal syndrome Hepato-renal syndrome

investigations CBC ESR leucocytosis

ascites

Ultrasond Tapping

spontaneous bacterial peritonitis 250 neutrophils polymorph 250 Peritonitis perforated appendix spontaneous bacterial peritonitis air under diaphragm X ray perforated appendix

air under diaphragm

Perforated appendix X ray air under diaphragm appendix

spontaneous bacterial peritonitis spontaneous bacterial peritonitis mono organism E.Coli

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GIT Dr. Shaf3y

Perforated appendix bacteroid E.Coli

spontaneous bacterial peritonitis uniorganism infection It is a uniorganism infection

gram negative

What is your treatment third generation Cephalosporin

Once spontaneous bacterial peritonitis Always spontaneous bacterial peritonitis Which means once attack of spontaneous bacterial peritonitis Liver end stage liver treatment

treatment

Liver transplant

Once spontaneous bacterial peritonitis Always spontaneous bacterial peritonitis Once spontaneous bacterial peritonitis liver spontaneous bacterial peritonitis

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GIT Dr. Shaf3y

transplant

spontaneous bacterial peritonitis

Liver spontaneous bacterial peritonitis third generation Cephalosporin antibiotics maintainace cadaveric

ascites ascites Liver cell failure Kidney Kidney Kidney Kidney

Hepato-renal syndrome

Liver cell failure

Hepato-Renal Syndrome
Liver cell failure
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hepato-renal syndrome Liver disease Kidney

52

GIT Dr. Shaf3y

Liver cell failure renal failure

renal failure hepato-renal syndrome hepato-renal syndrome definition It is acute renal failure in a patient with liver cell failure with a normal histology or pathology liver cell failure renal failure biopsy

hepato renal syndrome acute renal failure Normal Kidney biopsy

hepato renal syndrome liver cell failure renal failure blood supply kidney blood supply Hepato renal syndrome renal failure Kidney Kidney Liver cell failure Kidney Hypoalbuminemia Liver cell failure tissues
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GIT Dr. Shaf3y

blood volume Kidney

intra abdominal pressure

ascites renal vessels blood flow

Intra abdominal pressure ascites renal vessels renal blood flow

bilirubin angiotensin two Kidney catecholamines

vasoconstriction

Bilirubin Is very powerful vasoconstriction blood vsessels

obstructive jaundice Mannitol

obstructive jaundice as pre operative preparation Mannitol

Kidny Protect renal blood flow vasoconstriction vasoconstriction bilirubin

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GIT Dr. Shaf3y

obstructive jaundice Mannitol

vasoconstriction

bilirubin

hepato renal syndrome definition It is acute renal failure in a patient with history of liver cell failure with a normal renal pathology mechanism decrease renal blood flow

blood vessels

fluid kidney

albumin blood flow

intra abdominal pressure ascites renal vessels

catecholamines

angiotensin two bilirubin Kidney vasoconstriction

G.I.T.

portal hypertension Portal hypertension shunted towards blood splanchnic area Away from the kidney

Portal hypertension congested engorged blood vessels G.I.T. direct towards Kidney clinical pictures Acute renal failure manifestations of liver cell failure
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GIT Dr. Shaf3y

Precipitating factors Liver cell failure hepato renal syndrome suddenly << blood volume Liver cell failure Hepato renal syndrome hematemesis blood volume severe diuresis severe diarrhea Severe vomiting suddenly Paracentesis blood volume Suddenly

Sepsis spontaneous bacterial peritonitis peripheral vasodilation periphery directed Away from the kidney extensive paracentesis sepsis hematemesis diarrhea Vomiting

hepato renal syndrome cause

cause liver transplant hepato renal syndrome Liver Kidney

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GIT Dr. Shaf3y

blood volume blood volume albumin albumin Intra venous albumin Kidney blood flow

blood vessels

fluid

vasoconstriction dopamine renal dose renal vessesl vasodilatation vasodilatation vasoconstriction somatostatin Portal hypertension splanchnic vessels vasoconstriction G.I.T. G.I.T.

G.I.T.

alpha agonist alpha receptors activation blood vessels vasoconstriction

Kidney

Albumin albumin blood flow

Kidney

Dopamine renal dose blood flow

G.I.T.

vasoconstriction

Somatostatin

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GIT Dr. Shaf3y

paracentesis abdominal pressure sudden gradually << Paracentesis renal vessels Pressure

liver transplant Liver transplant

dialysis dialysis

hepato-renal syndrome Type one Type two

hepato renal syndrome Type one and type two type one criteria type one Doubling of the serum creatinine above 2.5 mg Doubling of the serum creatinine to above 2.5 mg Or, Reduction of the glomerular filtration rate 20 To less than 20 ml per minute Within two weeks

type one hepato renal syndrome double serum creatinine 2.5 1.5 0.6 creatinine double type one

2.8

creatinine type one

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GIT Dr. Shaf3y

2.5 double creatinine

Type two It is rise of creatinine to above 1.5 mg Or, Reduction of glomeular filtration rate to less than 40 ml per minute Over period more than two weeks kidney hepato renal Neomycin Neomycin Oral antibiotics renal failure

cirrhosis

Hepatitis glomerulonephritis cirrhosis

hepatitis virus

Hepatitis virus glomerulonephritis

amyloidosis Wilson disease haemochromatosis kidney Liver At the same time

genitalia endocrinal system genitalia

Liver cell failure estrogen

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endocrinal manifestations Prolactin Liver

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GIT Dr. Shaf3y

estrogen galactorrhea male Prolactin

Gynecomastia Atrophy of the testis

soft

firm silky hair soft voice female distribution of hair triangle Pubic hair triangle

Infertility

females amenorrhea galactorrhea Lower limbs muscles skin skin jaundice jaundice

bone

Muscles

skin

yellowish discoloration of the skin

jaundice Caroteinaemia

spider navei spider navei vasodilator material

estrogen

prostaglandin

Nitric oxide

liver cell failure even normal individual pregnancy

characteristic

spider navei

thyrotoxicosis

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GIT Dr. Shaf3y

abdomen

upper part of the chest neck superior vena cava

distribution

blanches with pressure << spider navei

spider navei skin Itching scratching marks jaundice bile salts puritis

Palmer erythema Palmer erythema

palmer erythema Palmer erythema heads of metacarpals Hypothenar thenar pallor

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GIT Dr. Shaf3y

palmer erythema Is it characteristic for a patient with liver cell failure Normal persons jaundice skin spider navei palmer erythema pallor Liver cell failure pallor anemia edema edema << pallor

hemochromatosis skin pigmentation platelets purpura D.I.C. Purpura

palmer aponeurosis fibrosis alcoholic cirrhosis

findings

15 sign

Which is good skin skin Muscles

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GIT Dr. Shaf3y

atrophy Muscles

atrophy gluconeogenesis amino acids Muscles amino acids atrophy temporalis atrophy vastus medialis

Temporalis

Vastus medialis bone bone marrow

bone

anemia iron deficiency

bleeding peptic ulcer

bleeding varices

anemia of chronic illness

folic acid deficiency Liver hemolytic anemia

B12

Hypersplenism splenomegaly
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GIT Dr. Shaf3y

bone marrow failure

liver cirrhosis

hepatitis virus bone marrow aplastic anemia Interferons bone marrow failure platelets

chronic hepatitis

Hypersplenism B12 deficiency folic acid WBCs pan cytopenia

coagulation abnormalities PTT

blood PT

PT << factor 7 half life

hepatic encephalopathy renal

C.N.S. Ascites

manifestations of liver cell failure investigations of liver cell failure Liver function test Liver function test

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GIT Dr. Shaf3y

Liver function test

alkaline phosphatase

SGPT

SGOT

bilirubin variable << urobilinogen stercobilinogen globulins albumin prolonged << prothrombin time liver biopsy alpha feto protein

biphasic

treatment of liver cell failure treatment of liver cell failure

Treatment of ascites, treatment of encephalopathy Look above cirrhosis treatment of liver cell failure treatment of hepatic encephalopathy treatment of hepato renal syndrome treatment of ascites

G.I.T. 46 2013 15

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www.facebook.com/dr.tafreegh

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