Before starting Hepatology rotation, it is useful to read the Liver Section in the Oxford Handbook of Clinical Medicine. This refreshes your knowledge about Liver Diseases which you learned in medical school. This will help greatly for the whole rotation as you know and are comfortable with the basics of Hepatology including basic management of patients with Liver Diseases.

There are two teams in Hepatology - the main Hepatology Team (found under Hepatology in EPIC team lists) and the Hepatology Transplant Team (found under Hepatology Transplant team in EPIC). The Consultant in charge for that week is responsible for both teams but the juniors (and largely the registrars) only operate under one of the teams. As FY1s we are always on the Hepatology Team.

The Hepatology ward is located on D5 and this is where most of the patients are located. More unwell patients may be on D4 (IDA) or in ITU - these patients are more commonly looked after by the Transplant team however. Hepatology do not take general medical patients so if a patient is admitted under Hepatology and there is no bed available they will go to another ward as a Hepatology “Outlier”.

When you enter D5 the doctors officer is the first door on your left after the nurse's staff room. If you walk further down into the ward you will reach the nurses station.

There will be three juniors in total (one foundation/two SHOs or visa versa), one or two registrars and a consultant.

There are five main Hepatology consultants; Drs Gelson, Allison, Griffiths, Leithead and Mells. They each rotate so that one of them is on the ward at any one time for a two week block. For that two weeks they cover Transplant and the main Hepatology Ward and are on call 24 hours - it s a busy two weeks for them. They're all very approachable and helpful.

Every morning around 9 there is a board room with members of the MDT - the nurse in charge for the day and varying amounts of physiotherapists/OTs depending on who is available. We go through all the Hepatology patients to discuss how they are progressing and plans for discharge. We also alert the nurse in charge to any outliers we may have so that if a bed becomes available on D5 they can be transferred over.

Addenbrookes is a tertiary referral unit for liver patients so we have a lot of contact with other hospitals and often have patients transferred over from other hospitals. When a patient is transferred they will need clerking (see section below). This means that part of the job as a junior involves ringing other hospitals to try and get images/results transferred over. This is easiest to do through ringing switch and asking for whichever hospital you require, and then speaking to the operator at the other end. If you want images then you can be asked to be put through to that hospitals PACs department to request the images you want. You then have to contact the PACS department at Addenbrookes to get them uploaded.

Rotation is 4 months long, split into a 2 month hepatology stint (with evenings, lates and weekends), and another 2 month acute block (in either order - often in bits). The acute block is made up of time spent clerking in ED, time on MDU and you “service needs” block where you get sent to different teams depending on need. It is recommended that you try and take annual leave in your service needs block.

The week on Hepatology can vary greatly however things to be aware of during the week include:

Monday - Hepatology department teaching is at 1:30 on a Monday usually, this can be on a variety of topics and often lunch is provided! On a Monday afternoon is the first of the two specific Hepatology Endoscopy lists.

Wednesday - the liver transplant assessment patients tend to come in on a Wednesday (see below for what is involved)

Thursday - SHO teaching is on a Thursday afternoon

Friday - Transplant meeting is on Friday afternoon as well as the X-ray meeting and the Histopathology meeting. As juniors we do not often attend these but the registrars and consultant tend to be tied up in meetings for most of Friday afternoon. On a Friday morning is the second of the two specific Hepatology Endoscopy lists. Friday teaching for FY1s is 12-1.

Prior to the board round: - Check with sister/ on call doctor (if around) regarding anything that has happened over the night - When the Consultant comes back from morning report assign new patients to the Hepatology team - this is done by searing for the patient on EPIC, right clicking on their name, and then clicking the option that says “assign teams”. In the search box type Hepatology and ensure that this is the “primary team”. They will then come out on the Hepatology list. - Print out the Hepatology list for that day so you can scribble jobs on it.

There may already be a few things that you need to do before the board round. This can include ordering blood products for patients having procedures that day or going to US/ringing IR to discuss procedures you need to happen.

Board round: This normally starts around 9AM and last around 10-20 minutes (depending on how complex the patients are). As above it is an MDT discussion.

Ward round: Following this there is a ward round - often run by the Consultant or SpR running the WR. Once ward round is finished then just get going with the rest of the jobs until the day is done.

Many Hepatology patients have daily bloods (set on EPIC) so a full review of the bloods must be done every day.

At the end of the day hand over any remaining jobs to the 152241 bleep and head home!

There is a wide range of patients in Hepatology. Most common diagnoses you will see include NASH, alcohol-related liver disease (ARLD), viral hepatitis (particularly Hep C), autoimmune liver disease, alcoholic hepatitis and patients with biliary obstruction.

All first presentations of liver disease need a full liver blood screen - “Acute liver disease” and “Chronic liver disease” screen in EPIC. They largely all require US liver dopplers (and often on representation will need a new one). They require daily bloods often and close monitoring of renal function and electrolytes as these can often be deranged. All patients presenting with decompensated liver disease require a rigorous septic screen as sepsis is a common cause of decompensation. This often involves an ascitic tap (if ascites present) to exclude SBP.

Many patients will have deranged clotting but are nevertheless likely to be in a pro-coagulant state, so discuss with seniors if you have any queries about the appropriateness of prophylactic LMWH.

Prescribe carefully for liver patients - for example many are only one 500mg QDS of paracetamol rather than the standard 1g. Commonly prescribed items for liver patients include Pabrinex (for withdrawal), B12 and thiamine, chlordiazepoxide (also known as librium - and often prescribed as CIWA, see below), lactulose (we like our patients to have at least three bowel motions a day), rifaximin, antibiotics (both prophylactically - usually cipro, and treatment - often Taz), antifungals and HAS. HAS stands for Human Albumin Solution and it needs to be ordered from the lab as well as being prescribed on EPIC.

CIWA is a specialised regimen for giving chlordiazepoxide in alcohol withdrawal patients based on a scoring system. Patients will be assessed every hour for a variety of symptoms and if they score 10 or more will lbw given a dose of chlordiazepoxide. If they do not score they are not given it. This can only be done on MDU/MSEU and D5 - on other wards we have to use fixed dose chlordiazepoxide withdrawal.

Admission

There are three main routes of admission for the Hepatology patients:

- Admission through ED - same format as rest of hospital

- Referrals from other hospitals - as mentioned above, these patients need clerking in as you would a patient in ED and then often varying documentation chased from other hospitals. They will also be clerked in by an SpR.

- Elective admissions - there are a number of elective patients that attend the Hepatology ward and there is an elective patient list you can be added to the email list for so you know who is attending the ward each week. The main reasons patients come in include paracentesis, liver biopsies, TAE/TACE and for transplant assessment. See below for more information in regards to this.

Paracentesis patients often come in and out without you knowing too much about them. If they are a day patient they do not require clerking and the excellent specialist nurses (Fiona and Aileen) will see them and sort out their drain and send them home. A few patient, for different reasons, come in the day before their drain and these patients will need to be clerked in and have clotting/group and screen and other bloods. However, the specialist nurses will still organise everything in regards to their drain - we just have to do admission documentation and a discharge letter!

TAE stands for transarterial embolisation, TACE stands for transarterial chemoembolisation and SIRT stands for selective internal radiation therapy. They are all treatments used in treat HCC for patients not suitable for a resection. There is a template on epic .taeclerking that explains exactly how to clerk these patients. They normally come in the day before their procedure and the main job is to (briefly) clerk them in and ensure bloods are taken. IT is important to check clotting and get a group and save. Clotting needs to be checked so that, if necessary, this can be corrected prior to the procedure. This normally requires a lot of phone calling to blood bank! The patients will go down for their procedure in the morning and then are often well enough to go home later in the evening. Depending on the size of the ischaemic area post-embolisation they may have severe pain and some require a PCA.

Liver biopsy patients are similar to TAE/TACE/SIRT patients and require clerking and bloods taken to ensure clotting is checked on admission, normally the night before their procedure. Clotting needs to be corrected as necessary. With all biopsies it is important that the samples make it to the labs so they best thing to do is to ask ultrasound or interventional radiology to bleep you when they have collected the sample and to hand deliver it yourself (to level 5 in the lab block Histopathology). If it is an urgent sample you will need to do this and you will need to speak to the Histopathologist Consultant on call to process your sample urgently.

Liver Transplant assessment patients largely come in on a Wednesday and go home on a Friday after the Transplant meeting. They do not always stay in hospital, if they are well and no beds are available they sometimes go to the hostel overnight and present to the ward from 9-5 every day of their assessments/tests. There are a lot of tests that they have during this time (Echo, CT, lung function, sometimes psych assessment) but these are all organised by the Transplant coordinators. They main job for juniors to do is to ensure patients have an ECG done by the nursing staff on the ward and ensure ABGs are taken. We are also responsible for writing a quick discharge letter however we do not write the outcome of the Transplant assessment on this (if follows in a separate letter) so its very quick and easy! The SpRs are responsible for presenting these patients but they may ask you to chase up some investigations if necessary.

Discharge

This is largely the same as other wards in the hospital. It is important to ensure that TTOs/letters are written and that follow up (if needed) is organised - often by emailing the specific consultants secretary to arrange follow up. When completing TTOs for patients on methadone, the Substance Misuse team can help with follow up plans (i.e. when and where the patient will get their next prescription and how much we should supply) - if this isn't detailed in their note give them a call to check.

Booking endoscopies - people with bleeding varices need to be scoped urgently on a hepatology list often the same day/night that they are bleeding. You can request endoscopy on epic. Fill in the form specifying that the patient needs to be scoped by Hepatology for ?banding of oesophageal varices. Put your bleep number somewhere on the request. Then call Endoscopy and discuss the request with the nurse coordinator. Explain why it is urgent.

Urgent endoscopies can be done in endoscopy time outside of allocated lists if the consultant/registrar on the ward feels it is urgent enough and will be free to do the scope; in these cases explain this to the nurse coordinator after confirming it with the reg. On the weekend the endoscopy nurse on call may need to be called from home to come in!

If there are not enough slots on hepatology lists (common) for non-urgent endoscopies, you can try emailing the consultant doing the list to ask to overbook it, explaining that it is a Hep patient and why it needs to be done.

People with non-cirrhotic causes of upper GI bleeding (gastritis/etc) can be scoped on non-hepatology lists.

Booking ultrasounds - most patients with liver disease get a USS liver doppler during their admission. These are booked on epic under 'US doppler liver and portal system'. If appropriate, specify in the request USS liver doppler “to confirm portal vein patent” (this tells you that a TIPPS/liver transplant is possible).

Ascitic drains - FY1s cannot put in ascitic drains, but you may be asked to arrange one. To do so, either bleep Fiona Smith/Aileen Inte the specialist nurse and explain who needs a drain and why; see if she has time to do it. Or the SHO or Reg will do it. Some drains are done under ultrasound guidance in radiology - you need to discuss requests with the radiology SpR on call and will probably need to go down to the department to discuss in person with the radiologist doing the list. When people have drains they need to have 20% HAS replacement; we give 100mls 20% HAS (stat) for every 3L drained (indicate this schedule when prescribing). People with renal problems may have “limited drains” of about 6 litres and 100ml 20% HAS replacement every 2L drained; people with normal renal function will be drained 'dry' and can be harder to calculate HAS; prescribe and order HAS accordingly.

Ascitic taps - Your SpR or SHO will do these. F1/F2 can also do these under supervision. Remember to request the appropriate tests and indicate you have collected the samples on epic. Tests required will often include fluid biochemistry (protein, albumin, LDH etc - sample goes in white-top universal container to biochemistry), fluid cell count (sample goes in white-top universal container to microbiology), ascitic fluid culture (sample goes in blood culture bottles to microbiology). There is no specific request for ascitic fluid cell count on epic - request 'surgical site fluid' then type in 'ascitic fluid' in the request details/ comments. Do not request 'body fluid nucleated cell count'.

If you need a fluid cell count urgently (eg ? SBP) , then it is worth hand delivering samples to the microbiology lab on floor 6 yourself!

PICC/CVP lines Vascular access offer an excellent service (Mon-Fri only) - sorely required by our patients because they are sick/need CVP measurements/have rubbish peripheral access due to previous recreational activities. CVAT insertion forms are found by searching for the central venous access team on connect. Complete CVAT forms early and input the clotting and plts on the form. Then phone them to arrange what replacement they would be happy with (plts need to be >50 for a procedure), and sometimes FFP is also indicated, and arrange a rough time for the patient to be booked in that accounts for the time taken to give the blood products required/recheck plts if needs be. You can only order one pooled platelets at a time unless discussed with Haem SpR - if really low and patient has splenomegaly may need to arrange for platelets to be slowly (one hour bag) running through whilst they have their procedure.

The SpR is the go-to person, very rare that you would have to contact a Consultant urgently. The SpR tends to be around on the ward or nearby and is generally easy to contact if you need support. Hand over to the late person who will hand over to the night team.

On weekends there will be a consultant ward round each day. Make sure you know how to contact the SpR on call should you need to.

Main ward bleep tends to be 157371

There is a sheet of paper on the wall of the doctors office with lots of useful numbers.

Substance misuse team (Jonathan Wood and Rob) are a frequent presence on D5 and happy to help with any related issues - they are very helpful!

Adult SOVA issues go through Heather Ayles.

Hep specialist nurses and contact details are listed in the induction booklet.

Emma McColl is the ward sister and is always friendly and a fountain of knowledge.

Can sometimes be difficult to get home on time (6pm), but usually manage before 7pm. Plenty of zero days / annual leave during this rotation. We found the key thing is try to do as many jobs as possible on the ward round.

The Hepatology induction book as supplied by the consultants have useful names and contacts, as well as a basic outline of the job. Elective procedure workups are found here - consult to see which patients will require antibiotic prophylaxis - ALL HCC TAEs will require prophylaxis (as do SIRTs…but guidelines for this in the pipeline as this is relatively new here…), and those at risk of biliary sepsis, but check booklet/with senior if unsure

-Order group and saves for patients as risk of bleeding, and try to think about keeping them uptodate (expire 3 days after last blood product given) if the patient is at high risk of re-bleeding

-Arrange procedures early as clotting often needs to be looked at and corrected. Where possible liaise with the blood bank the day before or first thing in the morning to make sure FFP/ cryoprecipitate is ready before the procedure.

-Order and prescribe HAS en mass if possible - saves both you and the transfusion lab time! Don't forget to ask when it will be ready for.

-Communicate with the nurses as per changes to management, planned procedures and blood products/HAS to avoid delays/poor care/bad feeling

-it is possible to leave on time! Efficiency though and good delegation of jobs, is definitely key.