GASTROINTESTINAL SYSTEM

Diarrhoeal Diseases
Definition
The passage of unusually loose or watery stools, usually at least three times in a 24 hour period.
However, it is the consistency of the stools rather than the number that is most important.
Frequent passing of formed stools is not diarrhoea.

Epidemiology of diarrhoeal diseases

 Mode of transmission: - faecal-oral route
 Susceptible hosts – Failure to breastfeed until at least 2yrs of life
Malnutrition
Measles
Immunodeficiency or immunosuppression
Age (1st 2yrs of life) – due to combined effects of declining
maternal acquired antibodies and lack of active immunity in infants

Aetiology
 Bacteria - e.g. E. coli, Proteus, Shigella, Salmonella, Vibrio Cholerae
 Viruses - e.g. Rota virus
 Parasites - e.g. G. lamblia, E. histolytica
 Fungi - e.g. Candida
 Disaccharidase deficiency
 Systemic infections - e.g. Algid malaria

Major contributory factors

 Mismanaged feeding:
- Failure to take exclusive breast feeding for first 4-6 months of life
- Using feeding bottles for infant
- Storing cooked food at room temperature
 Poor sanitation:
- Using contaminated drinking water
- Failure to wash hands after defecation, after disposing of faeces or before
handling food
- Failure to dispose faeces hygienically
 Malnutrition
 Immunosuppression, immune deficiency
Types of diarrhoeal diseases
Four clinical types
1. acute watery diarrhoea (including cholera), which lasts several hours or days
2. acute bloody diarrhoea, which is also called dysentery
3. persistent diarrhoea, which lasts 14 days or longer
4. diarrhoea with severe malnutrition (marasmus or kwashiorkor)

Complications of acute watery diarrhoea

 Malnutrition
 Fluid and electrolytes imbalance:
o dehydration, shock
o hypokalaemia
o metabolic acidosis
o isotonic dehydration
o hypertonic (hypernatraemic) dehydration
o hypotonic (hyponatraemic) dehydration
o hypocalcemia and
o hypomagnesemia
 Seizures due to hypoglycaemia, hyperthermia, hyper/hyponatraemia
 Septicaemia
 Secondary lactose intolerance
 Haemolytic uraemic syndrome

Pathophysiology of diarrhoeal diseases

Intestinal physiology
- Caused by disturbance in mechanism of transport of water and electrolytes in the small
intestine
- Water and electrolytes are simultaneously absorbed by villi and secreted by crypts of
bowel epithelium which cause two directional flows between intestinal lumen and blood
- Any change in two directional flow results in reduced net absorption or increased
secretion causing diarrhoea

Mechanism of watery diarrhoea

- Secretory mechanism
 when absorption of sodium by villi is impaired and secretion of the chloride in
crypts is increased; loss of water and salts from body as watery stool (may result
from action on the bowel mucosa by bacterial toxins such as E.coli, Vibrio
cholerae or virus)
- Osmotic mechanism
  osmotically active substance is ingested, when poorly absorbed – diarrhoea
occurs. E.g. in lactase deficiency – the ingested lactose can cause diarrhoea.

Assessment of a child with diarrhoea

History
Ask the mother or other caretaker about:
 presence of blood in the stool
 duration of diarrhoea
 number of watery stools per day
 number of episodes of vomiting
 presence of fever, cough, or other important problems (e.g. convulsions, recent measles)
 pre-illness feeding practices
 type and amount of fluids (including breastmilk) and food taken during the illness
 drugs or other remedies taken
 immunization history

Physical examination
First, check for signs and symptoms of dehydration.
Look for these signs:
 General condition: is the child alert; restless or irritable; lethargic or unconscious?
 Are the eyes normal or sunken?
 When water or ORS solution is offered to drink, is it taken normally or refused, taken
eagerly, or is the child unable to drink owing to lethargy or coma?

Feel the child to assess:

Skin turgor - When the skin over the abdomen is pinched and released, does it flatten
immediately, slowly, or very slowly (more than 2 seconds)?

Then, check for signs of other important problems.

Look for these signs:
 Does the child's stool contain red blood?
 Is the child malnourished?
 Is the child coughing? If so, count the respiratory rate to determine whether breathing is
abnormally rapid and look for chest indrawing.

Take the child's temperature:

 Fever may be caused by severe dehydration, or by a non-intestinal infection such as
malaria or pneumonia.

Management
Determine the degree of dehydration and select a treatment plan

A B C
LOOK AT:
CONDITION Well, alert Restless, irritable Lethargic or
unconscious
EYES Normal Sunken Sunken
THIRST Drinks normally, not Thirsty, drinks eagerly Drinks poorly, or not
Thirsty able to drink
FEEL: SKIN PINCH Goes back quickly Goes back slowly Goes back very slowly
DECIDE The patient has If the patient has two If the patients has two
NO SIGNS OF or or
DEHYDRATION more signs in B, there more signs in C, there
is is
SOME SEVERE
DEHYDRATION DEHYDRATION
TREAT Use Treatment Pan A Weigh the patient, if Weigh the patient and
possible, and use use
Treatment Plan B Treatment Plan C
URGENTLY

Objectives
The objectives of treatment are to:
• prevent dehydration, if there are no signs of dehydration
• treat dehydration, when it is present
• prevent nutritional damage, by feeding during and after diarrhoea and
• reduce the duration and severity of diarrhoea, and the occurrence of future episodes, by giving
supplemental zinc.

Treatment Plan A: home therapy to prevent dehydration and malnutrition

Rule 1: Give the child more fluids than usual, to prevent dehydration
What fluids to give - Wherever possible, these should include at least one fluid that normally
contains salt. Plain clean water should also be given.
Suitable fluids
Most fluids that a child normally takes can be used. It is helpful to divide suitable fluids into two
groups:
Fluids that normally contain salt, such as:
• ORS solution
• salted drinks (e.g. salted rice water or a salted yoghurt drink)
• vegetable or chicken soup with salt

ORS solution
Composition of reduced (low) osmolarity ORS solution
Reduced osmolarity ORS grams/litre mmol/litre
Sodium chloride 2.6 Sodium 75
Glucose, anhydrous 13.5 Chloride 65
Potassium chloride 1.5 Glucose, anhydrous 75
Trisodium citrate, dihydrate 2.9 Potassium 20
Citrate 10
Total Osmolarity 245

Fluids that do not contain salt, such as:

• plain water
• water in which a cereal has been cooked (e.g. unsalted rice water)
• unsalted soup
• yoghurt drinks without salt
• green coconut water
• weak tea (unsweetened)
• unsweetened fresh fruit juice.

Unsuitable fluids
A few fluids are potentially dangerous and should be avoided during diarrhoea.
Some examples are:
• commercial carbonated beverages
• commercial fruit juices
• sweetened tea.

Other fluids to avoid are those with stimulant, diuretic or purgative effects, for example:
• coffee
• some medicinal teas or infusions.

How much fluid to give

The general rule is: give as much fluid as the child or adult wants until diarrhoea stops.
As a guide, after each loose stool, give:
 children under 2 years of age: 50-100 ml (a quarter to half a large cup) of fluid
 children aged 2 up to 10 years: 100-200 ml (a half to one large cup)
 older children and adults: as much fluid as they want

Rule 2: Give supplemental zinc (10 - 20 mg) to the child, every day for 10 to 14 days
By giving zinc as soon as diarrhoea starts, the duration and severity of the episode as well as the
risk of dehydration will be reduced. By continuing zinc supplementation for 10 to 14 days, the zinc
lost during diarrhoea is fully replaced and the risk of the child having new episodes of diarrhoea in
the following 2 to 3 months is reduced.

Rule 3: Continue to feed the child, to prevent malnutrition

The infant usual diet should be continued during diarrhoea and increased afterwards. Food
should never be withheld and the child's usual foods should not be diluted. Breastfeeding should
always be continued.

What foods to give - depends on the child's age, food preferences and pre-illness feeding
pattern; cultural practices are also important. In general, foods suitable for a child with diarrhoea
are the same as those required by healthy children.

How much food and how often - Offer the child food every three or four hours (six times a day).
Frequent, small feedings are tolerated better than less frequent, large ones.
After the diarrhoea stops, continue giving the same energy-rich foods and provide one more meal
than usual each day for at least two weeks. If the child is malnourished, extra meals should be
given until the child has regained normal weight-for-height.

Rule 4: Take the child to a health worker if there are signs of dehydration or other
problems

The mother should take her child to a health worker if the child:
• starts to pass many watery stools;
• has repeated vomiting;
• becomes very thirsty;
• is eating or drinking poorly;
• develops a fever;
• has blood in the stool; or
• the child does not get better in three days.

Treatment Plan B: oral rehydration therapy for children with some dehydration
Children with some dehydration should receive oral rehydration therapy (ORT) with ORS solution
in a health facility following Treatment Plan B
Children with some dehydration should also receive zinc supplementation as described above.

How much ORS solution is needed?

Approximate amount of ORS to give in the first 4 hours
Age < 4 months 4-11 12-23 2-4 years 5-14 years 15 years or
months months older
Weight < 5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9 kg 30 kg or
more
In ml 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

If the child's weight is known, this should be used to determine the approximate amount of
solution needed. The amount may also be estimated by multiplying the child's weight in kg times
75 ml.
If the child's weight is not known, select the approximate amount according to the child's age.

The exact amount of solution required will depend on the child's dehydration status.
If a child wants more than the estimated amount of ORS solution, and there are no signs of over-
hydration, give more.
Oedematous (puffy) eyelids are a sign of over-hydration. If this occurs, stop giving ORS solution,
but give breastmilk or plain water, and food. Do not give a diuretic. When the oedema has gone,
resume giving ORS solution or home fluids according to Treatment Plan A.

How to give ORS solution

A family member should be taught to prepare and give ORS solution. The solution should be
given to infants and young children using a clean spoon or cup.
Feeding bottles should not be used. For babies, a dropper or syringe (without the needle) can be
used to put small amounts of solution into the mouth.
Children under 2 years of age should be offered a teaspoonful every 1-2 minutes; older children
(and adults) may take frequent sips directly from the cup.
Vomiting often occurs during the first hour or two of treatment, especially when children drink the
solution too quickly, but this rarely prevents successful oral rehydration since most of the fluid is
absorbed. After this time vomiting usually stops. If the child vomits, wait 5-10 minutes and then
start giving ORS solution again, but more slowly (e.g. a spoonful every 2-3 minutes).

Monitoring the progress of oral rehydration therapy

Check the child from time to time during rehydration to ensure that ORS solution is being taken
satisfactorily and that signs of dehydration are not worsening.
If at any time the child develops signs of severe dehydration, shift to Treatment Plan C.
After four hours, reassess the child fully, following the guidelines in Table 1. Then decide what
treatment to give next:
If signs of severe dehydration have appeared, intravenous (IV) therapy should be started
following Treatment Plan C.
• If the child still has signs indicating some dehydration, continue oral rehydration therapy by
repeating Treatment Plan B. At the same time start to offer food, milk and other fluids, as
described in Treatment Plan A, and continue to reassess the child frequently.
• If there are no signs of dehydration, the child should be considered fully rehydrated. When
rehydration is complete:
- the skin pinch is normal;
- thirst has subsided;
- urine is passed;
- the child becomes quiet, is no longer irritable and often falls asleep.
Teach the mother how to treat her child at home with ORS solution and food following Treatment
Plan A. Give her enough ORS packets for two days. Also teach her the signs that mean she
should bring her child back.

Giving Zinc
Begin to give supplemental zinc, as in Treatment Plan A, as soon the child is able to eat following
the initial four hour rehydration period.

Giving food
Except for breastmilk, food should not be given during the initial four-hour rehydration period.
However, children continued on Treatment Plan B longer than four hours should be given some
food every 3-4 hours as described in Treatment Plan A.
All children older than 6 months should be given some food before being sent home.

Treatment Plan C: for patients with severe dehydration

Guidelines for intravenous rehydration
The preferred treatment for children with severe dehydration is rapid intravenous rehydration,
following Treatment Plan C.
If possible, the child should be admitted to hospital.

Guidelines for intravenous treatment of children and adults with severe dehydration
Start IV fluids immediately. If the patient can drink, give ORS by mouth until the drip is set up.
Give 100 ml/kg Ringer's Lactate Solution divided as follows:

Age First give 30 ml/kg in Then give 70 ml/kg in

Under 12 months (infants) 1 hour 5 hours
Older 30 minutes 2 ½ hours

 Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more
rapidly.
 After six hours (infants) or three hours (older patients), evaluate the patient using the
assessment chart. Then choose the appropriate Treatment Plan (A, B or C) to continue
treatment.
  If Ringer's Lactate Solution is not available, normal saline may be used.
 Repeat once if radial pulse is still very weak or not detectable.

Prevention
1. Breastfeeding
- During the first 6 months of life, infants should be exclusively breastfed. Exclusively breastfed
babies are much less likely to get diarrhoea or to die from it than are babies who are not breastfed
or are partially breastfed. Breastfeeding should ontinue until at least 2 years of age.
2. Improve feeding practices
- Complementary foods should normally be started when a child is 6 months old. Good feeding
practices involve selecting nutritious foods and using hygienic practices when preparing them.
3. Use of safe water
- The risk of diarrhoea can be reduced by using the cleanest available water and protecting it from
contamination.
4. Handwashing
- The risk of diarrhoea is substantially reduced when family members practice regular
handwashing. All family members should wash their hands thoroughly after defecation, after
cleaning a child who has defecated, after disposing of a child's stool, before preparing food, and
before eating. Good handwashing requires the use of soap or a local substitute, such as ashes or
soil, and enough water to rinse the hands thoroughly.
5. Food safety - key messages concerning the preparation and consumption of food:
• Do not eat raw food, except undamaged fruits and vegetables that are peeled and eaten
immediately;
• Wash hands thoroughly with soap after defecation and before preparing or eating food;
• Cook food until it is hot throughout;
• Eat food while it is still hot, or reheat it thoroughly before eating;
• Wash and thoroughly dry all cooking and serving utensils after use;
• Keep cooked food and clean utensils separately from uncooked food and potentially
contaminated utensils; and
• Protect food from flies by means of fly screens.
6. Use of latrines and safe disposal of stools
7. Measles immunization
Dysentery
Definition
Diarrhoea with visible blood in the stool.

Clinical features
 Visible blood in diarrhoeal stool
 Fever
 Cramping abdominal pain, tenesmus
 Weight loss and worsening of nutritional status
 Severe complications ( toxic megacolon , intestinal perforation, rectal prolapse,
convulsion , septicaemia, haemolytic uraemic syndrome)

Diagnosis
o Stool R.E- RBC and pus cells in the stool, trophozoites of E. histolytica (rare in children
under 5 yrs)
o Stool for culture and sensitivity – to detect pathogenic bacteria

Management

 Antimicrobial therapy
 Trimethoprim-sulphamethoxazole – dose TMP 4 mg/kg/dose and SMX 20 mg/kg/dose for
2 days or
 Norfloxacin – 10mg/kg/dose b.d. for 2 days
 if not improved or presence of trophozoites form of E.histolytica in stool examination add
Metronidazole (oral) – 10 mg/kg/dose t.d.s. for 5 days

 Fluids – Evaluate signs of dehydration and treated accordingly.

 Feeding – Continue feeding in order to prevent nutritional damage.
 Follow up – who not showing clear improvement within 2 days and high risks (infants,
 malnourished child, dehydrated patients) should be closely followed up.
Persistent diarrhoea
Definition
 Diarrhoea episode lasts for 14 days or longer.

Risk factors
 Malnutrition
 Recent introduction of animal milk or formula milk
 Young age(under 18 months of age)
 Immunological impairment
 Recent diarrhoea

Investigations
 Stool R.E
 Stool for culture and sensitivity
 Stool for reducing substance.
 Stool pH
Treatment
 Fluid and electrolytes replacement
 Assess hydration status and treat accordingly.
 Nutritional therapy(important aspect of treatment )
o Ensure full energy intake i.e.110kcal/kg/day by giving thick cereal with vegetable
oil.
o Give frequent small meals, at least 6 times a day.
o provide supplementary vitamins and minerals
o Give extra meal each day for at least one month.
 Anti-diarrhoeal drugs should not be given.
 A course of appropriate antimicrobial and antiprotozoal therapy for enteropathogenic E.
coli, Giardiasis, E. histolytica.

Preventive strategies of diarrhoeal diseases

 Breast feeding
Exclusive breast feeding – during 1st 6 months and continued at least to 2 years of age (to
reduce risk of severe diarrhoea and other serious infection.)
 Weaning practices should begin at 6 months.
 Proper use of water for hygiene and drinking
 Hand washing
 Use of sanitary latrines
 Safe disposal of stool of young children
 Measles immunization
LIVER DISORDERS
Viral Hepatitis
Causal organisms of viral hepatitis
1. Hepatitis A virus
2. Hepatitis B virus
3. Hepatitis C virus
4. Hepatitis D virus
5. Hepatitis E virus
6. Non A-E viral hepatitis
7. Cytomegalovirus
8. Epstein-Barr virus
9. Herpes simplex virus

Incubation period, mode of spread, nature of disease and prevention of hepatitis A, B, C, D,

and E

Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E

Incubation 2-4 wk 4-20 wk 2-26 wk 6-9 wk 3-8 wk
Spread
Faeces Yes No No No Yes
Blood Uncommon Yes Yes Yes No
Saliva Yes Yes Yes ? ?
Sexual Uncommon Yes Uncommon Yes ?
Vertical No Yes Uncommon Yes No
Chronic No Yes Yes Yes No
infection
Prevention
Active Vaccine Vaccine No Prevented by No
Passive Immune serum Hyperimmune No Hepatitis B No
globulin serum globulin vaccination

Phases of the clinical course of Hepatitis

1. The pre-icteric phase – prodromal symptoms usually precede the development of jaundice
by few days to 2 weeks.
 Chills, malaise, and headache
 GI symptoms – anorexia and nausea may be prominent and vomiting and diarrhoea
may follow.
  A steady upper abdominal pain
 Splenomegaly may occur
 Arthralgia, arthritis and skin rashes may occur in HBV infection
2. The icteric phase – dark urine and yellow tint to the sclera herald the onset of jaundice.
 As obstruction to the biliary canaliculi develops, the jaundice deepens, the stools
become paler, the urine darker and the liver more easily palpable.
3. The convalescent phase – appetite improves and GI symptoms diminish in intensity.
 The jaundice recedes, the stools and urine regain their normal colour, the liver
enlargement regresses.
 In the course of 3-6 weeks the majority of cases recover.

 Mild cases may run an anicteric course recognized only because of known contact with a
definite case or by association with vague GI complaints or malaise with bilirubinuria and
biochemical evidence of hepatic dysfunction.

Signs and symptoms of hepatocellular failure

Signs
 Increasingly severe jaundice, anorexia, vomiting
 Change in sleep rhythm,
 Spontaneous bleeding into skin or GI tract may occur.
 Ascites may develop
 Flapping tremor
 Tendon reflexes become increased, bilateral extensor planter responses
 Change in behavior
 Deterioration in hand writing, inability to perform the simple mental arithmetic tasks,
constructional apraxia
 Fetor hepaticus – sweet musty odour to the breath
 Eventually decerebrate or decorticate posture, and become unconscious.
 Hypotonia and areflexia occur terminally

Symptoms
 Lethargy, verbal confusion
 Irrational hyperactivity
 Restlessness, disorientation
 Repeated yawning, and sucking movement
 Apathy, stupor, and coma

Investigations
1. Liver function test including transaminases
   plasma aminotransferase activity exceeding 400U/l – most striking abnormality.
  plasma bilirubin – reflects the severity of the jaundice.
  alkaline phosphatase activity – marked cholestasis develops.
 Normal albumin concentration
2. Bilirubinuria is an early finding, usually continuing into the convalescent period. Mild
proteinuria may occur.
3. Prolongation of prothrombin time is a reliable indication of severe liver damage.
4. The white cell count is normal or low in uncomplicated cases.
5. Hepatitis serology for A, B, E, CMV and EB virus infection
6. Detection of HBs Ag

Differential diagnosis
1. Hepatitis due to toxin and drugs
2. Weil’s disease (Leptospirosis)

Complications
1. Acute hepatic failure
2. Renal failure
3. Aplastic anaemia
4. Chronic hepatitis
5. Cirrhosis (with Hepatitis B, C)
6. Hepatocellular carcinoma

Management
Only the more severely affected patients require care in hospital, principally to allow early
detection of developing acute hepatic failure.
1. No specific treatment
2. General supportive measure – diet, liver support, fluid, drugs to avoid
Diet:
- High calorie diet
- Initially due to nausea and anorexia, a light diet with fruit drinks and glucose should be given.
- Good protein intake should be encouraged.
- If vomiting is severe, IV fluid and glucose may be required.

Avoid taking drugs

Drugs should be avoided if possible, especially in severe hepatitis, because many are
metabolized in the liver. This applies especially to sedatives and hypnotics.

3. Management of hepatocellular failure – refer to cirrhosis of liver

Prevention
1. Environmental sanitation
2. Personal hygiene
3. Safe water supply
4. Proper sterilization of syringes and needles. Use of disposable syringes and needles is the
best method.
5. Screening of blood donors
6. Active immunization
 Routine immunization: with 3 doses at 0, 1, and 6 months interval or at birth, one and
six months of age in neonate. Booster dose is followed every 5 years.
 Management of babies born to HBsAg positive mothers
1. All the babies born to mothers carrying hepatitis B (HBsAg +ve) must be
immunized four doses: at birth, one, two, and twelve months with a blood
sample at 14 months to check antibody levels.
2. Babies born to mothers with high infectivity (are defined as those who are e
antigen positive, e antibody negative or both e antigen and e antibody
negative) must be given 2 ml (200 IU) immunoglobulin as well as vaccine,
ideally within the first 12 hours of life.
7. Health education

Prognosis
Viral hepatitis A
 Acute hepatic failure
 Chronic infection does not occur.

Viral hepatitis B
 90-95% has full recovery.
 5-10% will develop chronic infection. Chronic hepatitis B is asymptomatic and develops
complications such as cirrhosis (15-20%) and hepatocellular carcinoma.
 Chronic infection also common in immunodeficient individual such as Down's syndrome and
HIV infection.
 At /after delivery;
- if mother is HBe antigen positive - 85%
- if Hbe antibodies are present – 25% infants become carriers
- if HBs antigen positive alone – 10-20%.

Viral hepatitis C
 80% develop chronic infection.
 Chronic hepatitis C infections are usually asymptomatic. Most develop cirrhosis and
hepatocellular carcinoma.
Cirrhosis of the liver
Definition
Cirrhosis is characterized by hepatic parenchymal damage with fibrosis and nodular regeneration
throughout the liver, accompanied by distortion of normal lobular pattern.

Common causes in children

1. Idiopathic (cryptogenic)
2. Obstructive biliary diseases - Congenital extrahepatic biliary atresia, Neonatal hepatitis
syndrome, Choledochal cyst
3. Infection of the liver - Viral hepatitis B, C, or D
4. Cardiac causes – any congenital heart disease with heart failure
5. Drugs – Methotrexate
6. Metabolic disorders - Haemochromatosis (primary or secondary), Wilson's disease
(hepatolenticular degeneration), Alpha-1-antitrypsin deficiency
7. Persistent blockage of the venous return from the liver: e.g. veno-occlusive disease, Budd-
Chiari syndrome

Clinical features of hepatic cirrhosis

1. Hepatomegaly (although liver may be small)
2. Jaundice
3. Ascites
4. Circulatory changes - Spider telangiectasia, palmar erythema, cyanosis
5. Endocrine changes: (In adolescent) - Loss of libido, hair loss, Male: gynaecomastia, testicular
atrophy, impotence, Female: breast atrophy, irregular menses, amenorrhoea
6. Haemorrhagic tendency - Bruises, purpura, epistaxis, menorrhagia
7. Portal hypertension - Splenomegaly, collateral vessels, variceal bleeding, fetor hepaticus
8. Hepatic (portosystemic) encephalopathy
9. Other features - Pigmentation, digital clubbing, low-grade fever

Palmar erythema Spider telangiectasia

Clinical features of different stages of hepatic failure:

1. Pre-hepatic coma
 Apathy, inability to concentrate, confusion, disorientation, dementia
 Slow slurred speech
 Reversal of sleep pattern
 Constructional apraxia, inability to perform simple arithmetic tasks
 Flapping tremor
 Bleeding tendency (decreased coagulation factors)

2. Hepatic coma
 Precoma progressing to delirium and coma
 Hyper-reflexia, extensor planter response
 Fetor hepaticus

Investigations
1. Liver function test
 May be normal
 With the progression of cirrhosis – increasing bilirubin, and enzymes aminotransferase
level
2. Total and differential protein – a low albumin level with normal or increased gamma globulin
3. Prothrombin time
 Increased prothrombin time and could not be corrected by giving vitamin K.
 It provides the valuable prognostic information in patients with acute and chronic liver
failure.
4. USG abdomen – increased echogenicity, and variable liver size.
5. Liver biopsy
6. Viral markers of hepatitis B and C
7. Upper GI endoscopy to detect varicies

Management of cirrhosis
1. Removal of the cause
2. Maintenance of nutrition and water and electrolyte balance
 High protein diet
 Low sodium
3. Supportive treatment
 For ascites – frusemide alone or in combination with aldosterone antagonist
(spironolactone)
 If marked ascites – abdominal paracentesis

Management of Hepatocellular failure

Mainly supportive
1. Diet - protein restriction to 0.5 gram/kg/day or less
 Fluid restriction
2. Gut sterilization
 Bowel wash out
 Lactulose oral/enema
 Oral neomycin – to decrease the enteric bacteria that produces ammonia
3. Avoid hepatotoxic agents, nephrotoxic agents, benzodiazepines and sedatives e.g. morphine
4. General measures
 IV infusion of electrolytes & 10-20% of glucose solutions – to maintain normal potassium
concentration and blood glucose.
 A parenteral H2 receptor blocker is administered prophylactically to prevent potential GI
bleeding.
 Vitamins supplement – especially vitamin B and K
 For cerebral oedema – endotracheal intubation and hyperventilation
5. Orthotopic liver transplant

Complications of cirrhosis
1. Portal hypertension
2. Increased susceptibility to infection
3. Hepatoma
4. Malnutrition
5. Bleeding diathesis
6. Spontaneous bacterial peritonitis
7. Renal failure
8. Hepatic encephalopathy