1 Liver disorders Flashcards
remarks on hepatic failure
uncontrolled bleeding is one of the life-threatening features of liver disease and a potentially serious complication of liver failure
treatment of mild-to-moderat ascites
1) salt-restricted diet
2) diuretics
- spironolactone 50 to 200 mg/day
- amiloride 5 to 10 mg/day
furosemide is problematic because it can lead to over diuresis
remarks on paracetnesis
even if PT/INR is increased, paracentesis is considered safe unless there’s evidence of fibrinolysis (3D-brusing, ozzing from IV sites) or overt DIC
give IV albumin 6 to 8 g per liter of fluid removed, for amounts greater than 4L
example:
5L ascitic fluid drained
Give 20% Albumin 50mL vial (10 g per vial), 3.5 vial intravenous bolus now (35 grams)
remarks on SBP
most common life-threatening complication of ascites
classic presentation:
- fever
- diffuse abdominal pain and tenderness
- vomiting
- GI bleeding
- encephalopathy
diagnosis of SBP
ascitic fluid
WBC >1,000/mm3
or PMN >250/mL
or bacteria on GS
Tx of SBP
Cefotaxime or other 3rd-gen ceph
or IV fluoroquinolone
or oral fluoroquinolone in a very mild case with close follow up
the addition of IV albumin (1.5 g/kg at diagnosis, 1g/kg on day 3) to antiobiotic therapy may reduce renal faiulre and hospital mortality in patients with SBP
remarks on ascitic fluid
ascitic fluid typically has high O2 tension. Therefore, anaerobic organisms are not commonly seen
Other remarks on SBP
long-term PPI use promotes gut bacterial growth and translocation
temperature is the most common symptom encountered in patietns with SBP, which is a particularly useful clinical symptom as patietns with cirrhosis are typically hypothermic (statpearls)
absence of fever does NOT rule out SBP
Blood and urine cultures should be obtained before initiation of antibiotic therapy as results of these may. help point towards a source of infection and guide antibiotic therapy (statpearls)
antibiotics should not be given until ascitic fluid has been obtained for culture (uptodate)
“a single dose of broad-spectrum antibiotics can lead to no growth on bacterial culture in 86% of cases”
most common life-threatening complication of ascites
SBP
major cause of death in patients with SBP
renal failure
- develops in 30-40% of patients
- risk can be minimized by giving IV albumin (1.5 g/kg at diagnosis, then 1 g/kg on day 3)
» should be given when
»» crea >1 mg/dL
»> BUN >30 mg/dL
»> total bili >4 mg/dL
Define portal hypertension
defined as elevation of hepatic venous pressure gradient (HVPG) to >5 mm Hg
> 12 mm Hg –> at risk for variceal hemorrhage
most common cause of portal hypertension
cirrhosis (intrahepatic, sinusoidal)
endoscopic interventions for variceal bleeding
injection therapy (sclerotherapy)
band ligation
- should be repeated until obliteration of all varices is accomplished
remarks on hypersplenism
Marked by
- enarlged spleen
- thrombocytopenia
- leukopenia
- left-sided and LUQ pain
Hypersplenism with the development of thrombocytopenia is a common feature of patients with cirrhosis and is usually the first indication of portal hypertension
other remarks on complications of portal hypertension
HYPOTENSION is a well-known complication in patients with cirrhosis
- mainly stemming from portal hypertension, leading to splanchnic and systemic vasidilation
- via nitric oxide and other vasoactive molecules secondary to endothelial stretching and sheer stress
Hyperdynamic circulatory syndrome
- decreased MAP
- decreased SVR
- increased cardiac index
