12. Management of Chronic Liver Disease Flashcards
What are the functions of the liver?
- production of clotting factors, albumin, bile
- storage of energy
- metabolism of cholesterol
- detoxification/ filtration
Cirrhosis is characterized by replacement of ______________ with ____________.
normal liver tissue
abnormal nodules and fibrosis
What are some complications of cirrhosis?
- splenic congestion
- portal hypertension
- fluid accumulation (ascites)
- increased bilirubin
How is liver damage assessed?
- aminotransaminases (ALT, AST)
How is liver function assessed?
- albumin level
- coagulation factors
What lab levels are elevated in liver cirrhosis?
- bilirubin
- Alkaline phosphates and GGT
- ammonia
- PT/INR
What lab levels are decreased in liver cirrhosis?
- sodium and potassium
- platelets
What does the Child-Turcotte-Pugh class A indicate?
5-6 points: least severe disease
What does the Child-Turcotte-Pugh class B indicate?
7-9 points: moderate to severe disease
What does the Child-Turcotte-Pugh class C indicate?
10-15 points: most severe disease
What are signs of high bilirubin?
pruritus
jaundice
What are signs of decreased clotting factors?
bleeding and bruising
What are signs of low estrogen degradation?
- palmar erythema
- spider angiomata
- gynecomastia
What are signs of low albumin?
edema, ascites, pleural effusion, respiratory difficultay
What are signs of high ammonia?
confusion asterixis ataxia dysarthria hypoactive reflexes
What are some complications of cirrhosis?
- Portal HTN and varices
- hepatic encephalopathy
- ascites
- spontaneous bacterial peritonitis
- hepatorenal syndrome
- coagulopathy
Why does cirrhosis cause portal hypertension and what can result?
- changes in liver tissue causes resistance to blood flow
- liver begins to develop alternate blood flow routes = varices
- bleeding can occur in these high pressure vessels
What are the clinical presentations of portal HTN and varices?
- usually asymptomatic until bleeding occurs
- varices are detected via esophagogastroduodenoscopy
What is the treatment goal for portal HTN and varices?
- treatment is aimed at preventing variceal bleeding
- primary prophylaxis
- treatment of acute variceal hemorrhage
- secondary prophylaxis
What is primary prophylaxis for portal HTN and varices?
- non-selective Beta-blockers
propranolol 10 mg or nadolol 20mg - recent data with Carvedilol
- nitrates no longer recommended
What are strategies to manage acute variceal hemorrhage?
- fluid resuscitation
- correct coagulopathy and thrombocytopenia
- control bleeding
- prophylactic antibiotics
How can bleeding be controlled mechanically in acute variceal hemorrhage?
- EBL: endoscopic band ligation
- EIS: endoscopic injection sclerotherapy
- TIPS procedure
- Blakemore tube/tamponade
How can bleeding be controlled pharmacologically in acute variceal hemorrhage?
- octreotide* 50-100 mcg IV bolus + 25-50 mcg/hr
- vasopressin
Only patients with increased risk factors should receive prophylactic antibiotics in acute variceal bleeding. (T/F)
False: all patients with acute variceal bleeds
Acute variceal bleeding prophylactic antibiotic regimens are designed to target ____________.
Gram negative bacteria in the gut
What agents should be used for acute variceal bleeding prophylactic antibiotics?
norfloxacin (or cipro) 400 mg BID x 7 days
ceftriaxone 1g/day
What is the focus of secondary prophylaxis in acute variceal hemorrhage?
prevention of rebleeding
What strategies are used as secondary prophylaxis in acute variceal hemorrhage?
beta-blockers +/- EBL or EIS
TIPS procedure is last line
Hepatic encephalopathy is a relatively common complication of cirrhosis. (T/F)
True: up to 70%
Why does hepatic encephalopathy occur?
- shunting of blood bypasses the liver
- accumulation of gut-derived nitrogenous substances in systemic circulation
How is hepatic encephalopathy treated?
- avoid excess dietary protein
- lactulose
- antibiotics
What is the first line pharmacological treatment for hepatic encephalopathy?
lactulose
How does lactulose lower ammonia levels?
- laxative effect reduces absorption of ammonia
- diffusion of ammonia from bloodstream
How is lactulose dosed?
25 mL q 1-2 hrs and titrated down to 4 BM per day
What antibiotic agents are used to reduce ammonia?
- neomycin
- metronidazole
- rifaximin
What is ascites?
accumulation of lymph fluid in peritoneal cavity
At what level is ascites clinically detected?
≥ 1.5 L
What is SAAG and how is it calculated?
-serum ascites albumin gradient
(serum albumin - ascites fluid albumin)
- if SAAG > 1.1 = portal HTN
How is ascites treated?
- avoid hepatotoxins
- sodium restriction
- diuretics
- large volume paracentesis
What diuretic agents are used in ascites?
furosemide and spironolactone
When should albumin be supplemented?
> 5L removed: administer 6-8 g per liter of fluid removed
What is spontaneous bacterial peritonitis?
infection of ascitic fluid
What are the most common pathogens in spontaneous bacterial peritonitis?
- E.coli
- K. pneumonia
- Strep pneumonia
What is the diagnostic criteria for spontaneous bacterial peritonitis?
PMNs > 250 cells/mL
What is the treatment for spontaneous bacterial peritonitis?
broad spectrum antibiotics
albumin
What is the first line antibiotic agent for spontaneous bacterial peritonitis?
3rd generation cephalosporin: Cefotaxime 2g q8h or Ceftriaxone 2g q24h
What are alternate antibiotic agents for spontaneous bacterial peritonitis?
Ofloxacin 400mg BID
ESBL agents
What is the dosing of albumin in spontaneous bacterial peritonitis?
1.5 g/kg within 6 hours of admission and 1 g/kg on day 3 of admission
Who should receive spontaneous bacterial peritonitis prophylaxis?
- all patients who have had spontaneous bacterial peritonitis
- high risk patients:
prior variceal bleed + low protein ascites
cirrhosis and ascites
What are the agents of choice for antibiotic prophylaxis for spontaneous bacterial peritonitis?
norfloxacin 400 mg qd
ciprofloxacin 250-500 mg qd
levofloxacin 250 mg qd
alt: 1 Bactrim double strength daily
What is hepatorenal syndrome?
renal failure due to cirrhosis
What causes hepatorenal syndrome?
vasoconstriction to the kidneys = decreased renal perfusion
What are risk factors for hepatorenal syndrome?
- refractory ascites
- SBP
- LVP without replacing albumin
How is hepatorenal syndrome treated?
All of the following
- albumin 1g/kg/day initially then 25-50g/day thereafter
- octreotide 100-200 mcg SQ TID
- vasopressor
What vasopressor agents are used in hepatorenal syndrome?
terlipressin 0.5-2 mg IV
norepinephrine 0.5 - 3 mg/hr IV
midodrine 5-15 mg TID
Spontaneous Bacterial Peritonitis is diagnosed at a PMN cell count of greater 200. (T/F)
False: ≥ 250
Which of the following is MOST appropriate for primary prophylaxis against a variceal bleed?
a. Albumin
b. Octreotide
c. Midodrine
d. Propranolol
d. Propranolol
What diuretic combination is typically used to control ascites?
a. Metolazone and Spironolactone
b. Furosemide and Spironolactone
c. Bumetanide and Spironolactone
d. Torsemide and Spironolactone
b. Furosemide and Spironolactone
Which of the following antibiotics are appropriate for SBP treatment?
a. Ceftriaxone
b. Vancomycin
c. Linezolid
d. Daptomycin
e. All of the above
a. Ceftriaxone
What is the recommend dosing for albumin for treatment of SBP?
a. 1g/kg on Day 1 of admission
b. 1.5g/kg on Day 1 of admission
c. 1.5g/kg on Day 1 of admission and 1g/kg on Day 3 of admission
d. 1g/kg on Day 1 of admission and 1.5g/kg on Day 3 of admission
c. 1.5g/kg on Day 1 of admission and 1g/kg on Day 3 of admission
