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CHAPTER 8 | LIVERDISORDERS

of LT. All patients should have a cardiovascular assessment including electrocardiogram and transthoracic echocardiography plus consideration of coronary angiography and cardiopulmonary exercise testing in selected cases. Respiratory work- up includes chest X- ray, spirometry, and, when necessary, assessment of hepatopulmonary syndrome (which resolves with LT) and portopulmonary hypertension (which may improve with LT in certain cases [e.g. responders to pulmonary vasodilators]). HRS is usually a reversible cause of renal failure that responds to LT but should be carefully dierentiated from other causes of AKI.

Infectious complications are the leading cause of early post- LT mortality, and their prevention includes careful pre- operative screening and treatment of infection alongside post- operative antimicrobial prophylaxis. Active bacterial, fungal, and viral infection represent absolute contraindications to LT, and the potential recipient should rst be treated until there is clear radiological, clinical, and microbiological evidence of resolution.

Historically, PVT was considered an absolute contraindication to LT. However, improvements in medical care, surgical techniques, and radiological interventions now mean that patients transplanted with PVT have equivalent outcomes to those without.

A past history of treated cancer should not disqualify candidates from LT although a ve- year interval between curative cancer treatment and LT is preferred.

EASL Clinical Practice Guidelines:liver transplantation. J Hepatol. 206 Feb;64(2):433– 485. Doi:0.06/ j.jhep.205.0.006.

50. B. Hepatic artery thrombosis (HAT)

• HAT occurs in 1%– 7% of patients after LT

• Early HAT (<21days post- transplantation) usually presents as graft dysfunction and is a

common indication for urgent liver re- transplantation

The HA is reconstructed during LT. Stenotic lesions of the HA can cause signicant ischaemic injury of which HAT is the most common cause, occurring in 1%– 7% of patients following LT. Early HAT (<21days post LT) often presents as graft dysfunction with markedly elevated liver enzymes, jaundice, acidosis, and hypoglycaemia. Collateralization is more common in late HAT, which presents more insidiously with bile duct strictures (ischaemic cholangiopathy) and resultant biliary sepsis or abscess formation. Risk factors for HAT include smoking, increasing donor age, low donor weight, multiple arterial anastomoses, and previous HAT. CT angiography is the gold standard for diagnosis. Early diagnosis of HAT reduces septic complications, multi- organ failure and graft loss. Treatment of HAT is centred upon urgent establishment of the arterial circulation (if possible) with surgical revascularization, to reduce complications related to ischaemic cholangiopathy. However, more than 50% of cases of early HAT require urgent re- transplantation. Prevention of HAT post- LT includes the use of long- term antiplatelet agents, smoking avoidance, and tight control of atherosclerotic risk factors.

EASL Clinical Practice Guidelines:liver transplantation. J Hepatol. 206 Feb;64(2):433– 485. Doi:0.06/ j.jhep.205.0.006.

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chapter

NUTRITION

1. An 89- year old was admitted with a severe community- acquired

QUESTIONS

pneumonia. Their family reported that the patient was struggling to manage at home and they were concerned about ongoing weight loss. The family did not think the patient had eaten properly for the past seven days. The patient used to weigh 75kg but on this admission weighed 63kg. Their body mass index (BMI) was 24.6kg/ m2.

What is their Malnutrition Universal Screening Tool (MUST) score?

A. 0

B. 1

C. 2

D. 4

E. 6

Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor, Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press. DOI: 10.1093/oso/9780198834373.003.0009

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CHAPTER 9 | NUTRITION

2. A 67- year- old woman presented to the outpatient clinic with a 14- month

history of diarrhoea, nausea, fatigue, and 12kg weight loss. She had a past medical history of hypertension, chronic kidney disease, type 2 diabetes, osteoarthritis, and hypothyroidism.

Investigations:

Haemoglobin 116 g/ L Mean corpuscular volume (MCV) 87 fL Serum ferritin 21 µg/ L Serum C- reactive protein (CRP) <0.2 mg/ L Vitamin B12 421 ng/ L Serum folate 4.1 µg/ L Thyroid- stimulating hormone (TSH) 2.3 mU/ L IgA tissue transglutaminase antibody <0.2 U/ mL Total IgA 1.26 g/ L Human leucocyte antigen (HLA) status DQ2.5 homozygote Gastroscopy Scalloped duodenal mucosa Duodenal histology Marsh 3B villous atrophy and crypt

hyperplasia with intra- epithelial lymphocytosis

Which of her medications is most likely to be the cause of her symptoms?

A. Ibuprofen

B. Levothyroxine

C. Metformin

D. Olmesartan

E. Simvastatin

CHAPTER 9 | QUESTIONS

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261

3. A 46- year- old woman presented with a long history of fullness after

eating, nausea, and weight loss with a current BMI of 17.3kg/ m2. There was no history of diabetes, previous abdominal surgery, or psychiatric illness. Despite dietary manipulation and a trial of nasogastric feeding, she continued to lose weight.

Investigations:

Gastroscopy Normal Computed tomography (CT)

No evidence of bowel obstruction or malignancy chest and abdomen Gastric scintigraphy 85% retention at two hours

40% retention at four hours

What is the best next step in management?

A. Amitriptyline 10 mg once a day and refer for urgent psychiatric assessment

B. Commence parenteral nutrition

C. Long- term metoclopramide 10 mg three times a day

D. Refer for surgical jejunostomy

E. Trial of nasojejunal feeding

4. A 55- year- old woman with secondary progressive multiple sclerosis developed recurrent lower respiratory tract infections. Apercutaneous endoscopic gastrostomy was placed two years ago for long- term enteral tube feeding and to reduce aspiration risk. The patient presented with diculty ushing the tube and leakage around the gastrostomy site.

Which of the following statements is most accurate?

A. Balloon gastrostomies are more likely to become buried than ones with a silicon disc

B. Buried bumper syndrome is dicult to prevent even with good nursing aftercare

C. Buried bumper syndrome should be suspected if the enteral feed pump alarms regularly

D. Buried bumpers are mostly managed with surgical removal of the gastrostomy

E. Gastrostomy tubes can be safely advanced into the stomach within three days of initial

insertion

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CHAPTER 9 | NUTRITION

5. A 45- year- old man with Crohn’s disease presented to the emergency department with unsteady gait, impaired concentration, dysarthria, loose stools, and blurred vision. Following previous operations, he had been left with 80cm small bowel in continuity with a full colon. His only medications were omeprazole and loperamide. He denied any recreational drug use but admitted to consuming a large amount of beer over the past three days. His diet was poor, largely comprising carbohydrate- based meals. Examination revealed nystagmus and dysmetria on nger– nose testing. Abdomen was soft and non- tender.

Investigations:

Serum sodium 138mmol/ L Serum potassium 3.2mmol/ L Serum urea 2.1mmol/ L Serum creatinine 66mmol/ L Serum chloride 106mmol/ L Serum glucose 6.7mmol/ L Arterial pH 7.21 Arterial lactate 1.9mmol/ L

What is the most likely diagnosis?

Arterial HCO

A. Acute alcohol intoxication

B. Beer potomania

C. Diabetic ketoacidosis

D. D- lactic acidosis

E. Wernicke’s encephalopathy

8mmol/ L

6. A 45- year- old man with a history of small bowel Crohn’s disease had undergone multiple ileal resections for stricturing disease. His current anatomy was 80cm jejunum anastomosed to full colon with no evidence of active inammation. He presented with a one- day history of severe left loin pain radiating into his groin with macroscopic haematuria.

Investigations:

CT kidney, ureter, bladder Large non- obstructing calculus at the left vesico-

Which of the following dietary measures would you recommend?

A. Increasing dietary beetroot

B. Increasing dietary chocolate

C. Increasing dietary fat

D. Reducing dietary calcium

E. Reducing dietary spinach

ureteric junction

CHAPTER 9 | QUESTIONS

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263

7. A 19- year- old being managed for dysmotility and gastroparesis presented with ongoing weight loss and diarrhoea. Feeding via a surgical jejunostomy had not been tolerated due to pain at the insertion site and bloating on increasing rate of feed administration. The patient demanded this be removed. She was commenced on parenteral nutrition but would not allow the rate of feeding to be increased in line with recommendations from the nutrition team. The nursing sta commented that she could be manipulative, and the portering sta frequently saw her running up and down the stairs.

Investigations:

Urinary laxative screen Positive

What would be the next best step in management?

A. Nasogastric feeding

B. Refer to psychological medicine

C. Remove jejunostomy and continue current rate of parenteral feeding

D. Restart jejunal feeding against patient’s wishes

E. Sedate patient and increase rate of parenteral feeding

8. A 57- year- old was established on parenteral nutrition due to short bowel syndrome. They received 2 500 ml over 12 hours, 7 nights per week (1 400 kcal glucose, 14 g nitrogen, sodium 120mmol, potassium 60mmol, magnesium 14mmol). They were admitted with a suspected central line infection but were haemodynamically stable. Their vascular access was dicult but you were able to insert a 22G cannula.

What is the best option for management over the subsequent 24 hours?

A. Encourage the patient to drink water; no intravenous support required

B. Prescribe 1 litre 0.9% sodium chloride with 40mmol potassium chloride, 1 litre 0.9%

sodium chloride with 14mmol magnesium sulphate, and 500 ml 5% dextrose to be administered through the 22G cannula

C. Prescribe 1 litre 0.9% sodium chloride with 40mmol potassium chloride, 1 litre 5%

dextrose with 14mmol magnesium sulphate, and 500 ml 5% dextrose with 20mmol potassium chloride to be administered through the 22G cannula

D. Prescribe usual parenteral nutrition to be administered through the 22G cannula

E. Prescribe usual parenteral nutrition to be administered through the central venous catheter

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CHAPTER 9 | NUTRITION

9. A 56- year- old man had undergone small bowel resection with primary anastomosis in the context of small bowel volvulus. Following an anastomotic leak, he developed an enterocutaneous stula and is now six weeks following his last surgery. He had lost 12kg in weight and was losing 1200 ml of euent through the stula per day. He was haemodynamically stable and CRP had been reducing.

Investigations:

CT abdomen Multiple small intra- abdominal abscesses, too small to drain

radiologically

What of the following is most appropriate at present?

A. Commence octreotide

B. Laparoscopic formation of stoma proximal to stula

C. Prolonged course of antibiotics

D. Unrestricted oral intake

E. Urgent repeat laparotomy and washout

10. A 35- year- old woman was reviewed in clinic. She had been on home parenteral nutrition for eight years for short bowel syndrome and had had three central line infections. She had a thrombosed right internal jugular and left subclavian vein.

Investigations:

Parameter (units) 6months ago Currently

Serum bilirubin (μmol/ l) Serum alanine transferase (ALT) (U/ L) 37 153 Serum alkaline phosphatase (ALP) (U/ L) 117 326

What is the next most appropriate step in management?

A. Commence teduglutide

B. Commence ursodeoxycholic acid

C. Inform palliative care

D. Refer for intestinal transplantation assessment

E. Repeat blood tests in six months’ time and refer for FibroScan in the interim

24 94

CHAPTER 9 | QUESTIONS

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265

11. A 45- year- old woman with BMI 41kg/ m2 was referred to a bariatric surgeon to discuss weight loss surgery. Her preferred option is a laparoscopic adjustable gastric band (LAGB).

Which of the following statements is correct regarding LAGB?

A. Anastomotic leak is the most common cause of post- operative 30- day mortality

B. It induces greater weight loss at one year compared with sleeve gastrectomy (SG) and

Roux- en- Y gastric bypass (RY- GBP)

C. It is better at inducing remission of type 2 diabetes compared with RY- GBP

D. The long- term re- operation rate is more than 10%

E. There is a higher post- operative 30- day mortality compared with SG

12. A 47- year- old woman presented to the outpatient clinic with anaemia. Ayear ago, she had undergone bariatric surgery for morbid obesity with a RY- GBP at a private clinic abroad. She had lost over 60kg (45% of her original body weight) since the procedure. She reported recent symptoms of abdominal discomfort and bloating, along with atulence and loose stool. She also reported fatigue and some hair loss.

Which nutritional deciency would best explain the patient’s anaemia?

A. Copper

B. Folate

C. Iron

D. Thiamine

E. Vitamin B12

13. A 52- year- old woman was reviewed two months post Roux- en- Y gastric bypass. She complained of abdominal discomfort occurring approximately 45 minutes after meals. This was associated with nausea, watery diarrhoea, drowsiness, palpitations, and sweating. She has also had episodes of collapse an hour after mealtimes on two occasions.

What is the most likely diagnosis?

A. Cholelithiasis

B. Early dumping syndrome (EDS)

C. Gastro- gastric stula

D. Late dumping syndrome

E. Post- prandial vasovagal syncope

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chapter

NUTRITION

ANSWERS

1. D. 4

• Identifying patients at risk of malnutrition is a key component of care

• The MUST score is a validated tool for assessing risk of malnutrition and to trigger intervention

Malnutrition is common in health and social care settings, in older people, and in those with disease. It remains underdiagnosed and undertreated, yet is associated with increased healthcare utilization, costs, and poorer outcomes. Approximately one third of patients admitted to hospitals across the UK are at risk of malnutrition.

The MUST is a simple- to- use, validated tool to identify those patients at highest risk of malnutrition and to trigger intervention to reverse further nutritional decline (Table 9.1).

Table9.1 Malnutrition Universal Screening Tool (MUST) score

Score Body mass index

(BMI, kg/ m2)

0 >20 <5 -

1 18.5– 20 5– 10 -

2 <18.5 >10 if the patient is acutely ill and

Unplanned weight loss in past 3– 6months (%)

Acute illness score

there has been or is likely to be no nutritional intake for >5days

The total score ranges from 0– 6 (0=Low Risk, =Medium Risk, 2 or more=High Risk). Based on the risk score, patients may receive routine clinical care (Low Risk), observation of dietary intake and

reassessment (Medium Risk), or immediate referral to dietitian/ Nutrition Support Team (High Risk).

Stratton R, Smith T, Gabe S.Managing malnutrition to improve lives and save money. Malnutrition Action Group, British Association of Parenteral and Enteral Nutrition (BAPEN) October 208. Available at:https:// www.bapen.org.uk/ pdfs/ reports/ mag/ managing- malnutrition.pdf (accessed February 2020)

2. D. Olmesartan

• Angiotensin II receptor antagonists, such as olmesartan and telmisartan, can cause villous atrophy, leading to severe diarrhoea and weight loss

• Tissue transglutaminase antibodies are likely to be negative, although most will have a predisposing coeliac HLA type (HLA DQ2 or DQ8)

CHAPTER 9 | ANSWERS

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• Most patients rapidly improve upon discontinuation of the culprit medication

Diarrhoea is a potential side eect of all the listed medications. Olmesartan and telmesartan have both been reported to cause a sprue- like illness with diarrhoea, substantial weight loss, and seronegative villous atrophy, mimicking coeliac disease. Microscopic colitis and lymphocytic gastritis may also be present. Symptoms are often present for years before the drug responsible is identied. Most patients improve clinically, with resolution of the villous atrophy, upon discontinuing the drug.

Non- steroidal anti- inammatory drugs, such as ibuprofen, commonly cause diarrhoea as well as duodenitis, but would not be expected to cause villous atrophy. Thyroxine in excess can cause diarrhoea. However, the TSH is normal in this case. Metformin and simvastatin can both cause diarrhoea, but not villous atrophy.

Rubio- Tapia A, Herman ML, Ludvigsson JF etal. Severe spruelike enteropathy associated with olmesartan. Mayo Clin Proc. 202;87(8):732– 738. Doi:0.06/ j.mayocp.202.06.003.

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3. E. Trial of nasojejunal feeding

• Nasojejunal feeding should be strongly considered prior to placement of a surgical jejunostomy for gastroparesis

Gastroparesis is most commonly idiopathic, diabetic, or post- surgical. It aects women more than men and leads to overall shortened survival compared with age- and sex- matched controls. Gastric emptying should be considered delayed if retention on scintigraphy is more than 60% at two hours or 10% at four hours.

Nutritional management is multi- disciplinary and involves close liaison with specialist dietitians. When oral dietary modications have failed, enteral tube feeding should be considered. This usually entails post- pyloric feeding. Atrial of nasojejunal feeding to prove the patient is able to meet their nutritional requirements should be strongly considered prior to placement of a surgical jejunostomy. This is because some patients will have pan- enteric dysmotility and may not tolerate post- pyloric feeding. Parenteral nutrition should not be considered rst- line therapy for isolated gastroparesis.

Eating disorders may manifest with similar symptoms, but there is no suggestion in this case that urgent psychiatric evaluation is necessary. The anticholinergic side eects of amitriptyline may worsen the patient’s symptoms. Following an alert from the European Medicines Authority, longterm treatment with prokinetics, such as metoclopramide or domperidone, is not advised.

Camilleri M, Parkman HP, Sha MA etal. Clinical Guideline:Management of gastroparesis. Am J Gastroenterol. 203;08():8– 37. Doi:0.038/ ajg.202.373.

4. C. Buried bumper syndrome should be suspected if the enteral feed pump alarms regularly

• Buried bumper syndrome is an avoidable complication of gastrostomy placement

• It can be prevented by regular advancement of the tube 5– 10cm and gentle rotation but not within the rst seven days of placement

• Endoscopic techniques form the mainstay of management

For patients requiring enteral tube feeding for longer than 4– 6 weeks, gastrostomy insertion should be considered. While endoscopic placement is usually preferred, some patients may require radiological or surgical placement— for example, if the stomach is inaccessible endoscopically.

Buried bumper syndrome is a preventable complication whereby the internal xator becomes buried within the gastric mucosa or at the surface of the skin. It is more common with internal

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