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957 block 2 > 12. Management of Chronic Liver Disease > Flashcards

12. Management of Chronic Liver Disease Flashcards

1
Q

What are the functions of the liver?

A
  • production of clotting factors, albumin, bile
  • storage of energy
  • metabolism of cholesterol
  • detoxification/ filtration
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2
Q

Cirrhosis is characterized by replacement of ______________ with ____________.

A

normal liver tissue

abnormal nodules and fibrosis

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3
Q

What are some complications of cirrhosis?

A
  • splenic congestion
  • portal hypertension
  • fluid accumulation (ascites)
  • increased bilirubin
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4
Q

How is liver damage assessed?

A
  • aminotransaminases (ALT, AST)
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5
Q

How is liver function assessed?

A
  • albumin level

- coagulation factors

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6
Q

What lab levels are elevated in liver cirrhosis?

A
  • bilirubin
  • Alkaline phosphates and GGT
  • ammonia
  • PT/INR
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7
Q

What lab levels are decreased in liver cirrhosis?

A
  • sodium and potassium

- platelets

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8
Q

What does the Child-Turcotte-Pugh class A indicate?

A

5-6 points: least severe disease

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9
Q

What does the Child-Turcotte-Pugh class B indicate?

A

7-9 points: moderate to severe disease

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10
Q

What does the Child-Turcotte-Pugh class C indicate?

A

10-15 points: most severe disease

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11
Q

What are signs of high bilirubin?

A

pruritus

jaundice

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12
Q

What are signs of decreased clotting factors?

A

bleeding and bruising

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13
Q

What are signs of low estrogen degradation?

A
  • palmar erythema
  • spider angiomata
  • gynecomastia
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14
Q

What are signs of low albumin?

A

edema, ascites, pleural effusion, respiratory difficultay

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15
Q

What are signs of high ammonia?

A 
confusion
asterixis
ataxia
dysarthria
hypoactive reflexes
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16
Q

What are some complications of cirrhosis?

A
  • Portal HTN and varices
  • hepatic encephalopathy
  • ascites
  • spontaneous bacterial peritonitis
  • hepatorenal syndrome
  • coagulopathy
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17
Q

Why does cirrhosis cause portal hypertension and what can result?

A
  • 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
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18
Q

What are the clinical presentations of portal HTN and varices?

A
  • usually asymptomatic until bleeding occurs

- varices are detected via esophagogastroduodenoscopy

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19
Q

What is the treatment goal for portal HTN and varices?

A
  • treatment is aimed at preventing variceal bleeding
  • primary prophylaxis
  • treatment of acute variceal hemorrhage
  • secondary prophylaxis
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20
Q

What is primary prophylaxis for portal HTN and varices?

A
  • non-selective Beta-blockers
    propranolol 10 mg or nadolol 20mg
  • recent data with Carvedilol
  • nitrates no longer recommended
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21
Q

What are strategies to manage acute variceal hemorrhage?

A
  • fluid resuscitation
  • correct coagulopathy and thrombocytopenia
  • control bleeding
  • prophylactic antibiotics
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22
Q

How can bleeding be controlled mechanically in acute variceal hemorrhage?

A
  • EBL: endoscopic band ligation
  • EIS: endoscopic injection sclerotherapy
  • TIPS procedure
  • Blakemore tube/tamponade
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23
Q

How can bleeding be controlled pharmacologically in acute variceal hemorrhage?

A
  • octreotide* 50-100 mcg IV bolus + 25-50 mcg/hr

- vasopressin

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24
Q

Only patients with increased risk factors should receive prophylactic antibiotics in acute variceal bleeding. (T/F)

A

False: all patients with acute variceal bleeds

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25
Q

Acute variceal bleeding prophylactic antibiotic regimens are designed to target ____________.

A

Gram negative bacteria in the gut

26
Q

What agents should be used for acute variceal bleeding prophylactic antibiotics?

A

norfloxacin (or cipro) 400 mg BID x 7 days

ceftriaxone 1g/day

27
Q

What is the focus of secondary prophylaxis in acute variceal hemorrhage?

A

prevention of rebleeding

28
Q

What strategies are used as secondary prophylaxis in acute variceal hemorrhage?

A

beta-blockers +/- EBL or EIS

TIPS procedure is last line

29
Q

Hepatic encephalopathy is a relatively common complication of cirrhosis. (T/F)

A

True: up to 70%

30
Q

Why does hepatic encephalopathy occur?

A
  • shunting of blood bypasses the liver

- accumulation of gut-derived nitrogenous substances in systemic circulation

31
Q

How is hepatic encephalopathy treated?

A
  • avoid excess dietary protein
  • lactulose
  • antibiotics
32
Q

What is the first line pharmacological treatment for hepatic encephalopathy?

A

lactulose

33
Q

How does lactulose lower ammonia levels?

A
  • laxative effect reduces absorption of ammonia

- diffusion of ammonia from bloodstream

34
Q

How is lactulose dosed?

A

25 mL q 1-2 hrs and titrated down to 4 BM per day

35
Q

What antibiotic agents are used to reduce ammonia?

A
  • neomycin
  • metronidazole
  • rifaximin
36
Q

What is ascites?

A

accumulation of lymph fluid in peritoneal cavity

37
Q

At what level is ascites clinically detected?

A

≥ 1.5 L

38
Q

What is SAAG and how is it calculated?

A

-serum ascites albumin gradient
(serum albumin - ascites fluid albumin)
- if SAAG > 1.1 = portal HTN

39
Q

How is ascites treated?

A
  • avoid hepatotoxins
  • sodium restriction
  • diuretics
  • large volume paracentesis
40
Q

What diuretic agents are used in ascites?

A

furosemide and spironolactone

41
Q

When should albumin be supplemented?

A

> 5L removed: administer 6-8 g per liter of fluid removed

42
Q

What is spontaneous bacterial peritonitis?

A

infection of ascitic fluid

43
Q

What are the most common pathogens in spontaneous bacterial peritonitis?

A
  • E.coli
  • K. pneumonia
  • Strep pneumonia
44
Q

What is the diagnostic criteria for spontaneous bacterial peritonitis?

A

PMNs > 250 cells/mL

45
Q

What is the treatment for spontaneous bacterial peritonitis?

A

broad spectrum antibiotics

albumin

46
Q

What is the first line antibiotic agent for spontaneous bacterial peritonitis?

A

3rd generation cephalosporin: Cefotaxime 2g q8h or Ceftriaxone 2g q24h

47
Q

What are alternate antibiotic agents for spontaneous bacterial peritonitis?

A

Ofloxacin 400mg BID

ESBL agents

48
Q

What is the dosing of albumin in spontaneous bacterial peritonitis?

A

1.5 g/kg within 6 hours of admission and 1 g/kg on day 3 of admission

49
Q

Who should receive spontaneous bacterial peritonitis prophylaxis?

A
  • all patients who have had spontaneous bacterial peritonitis
  • high risk patients:
    prior variceal bleed + low protein ascites
    cirrhosis and ascites
50
Q

What are the agents of choice for antibiotic prophylaxis for spontaneous bacterial peritonitis?

A

norfloxacin 400 mg qd
ciprofloxacin 250-500 mg qd
levofloxacin 250 mg qd
alt: 1 Bactrim double strength daily

51
Q

What is hepatorenal syndrome?

A

renal failure due to cirrhosis

52
Q

What causes hepatorenal syndrome?

A

vasoconstriction to the kidneys = decreased renal perfusion

53
Q

What are risk factors for hepatorenal syndrome?

A
  • refractory ascites
  • SBP
  • LVP without replacing albumin
54
Q

How is hepatorenal syndrome treated?

A

All of the following

  • albumin 1g/kg/day initially then 25-50g/day thereafter
  • octreotide 100-200 mcg SQ TID
  • vasopressor
55
Q

What vasopressor agents are used in hepatorenal syndrome?

A

terlipressin 0.5-2 mg IV
norepinephrine 0.5 - 3 mg/hr IV
midodrine 5-15 mg TID

56
Q

Spontaneous Bacterial Peritonitis is diagnosed at a PMN cell count of greater 200. (T/F)

A

False: ≥ 250

57
Q

Which of the following is MOST appropriate for primary prophylaxis against a variceal bleed?

a. Albumin
b. Octreotide
c. Midodrine
d. Propranolol

A

d. Propranolol

58
Q

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

A

b. Furosemide and Spironolactone

59
Q

Which of the following antibiotics are appropriate for SBP treatment?

a. Ceftriaxone
b. Vancomycin
c. Linezolid
d. Daptomycin
e. All of the above

A

a. Ceftriaxone

60
Q

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

A

c. 1.5g/kg on Day 1 of admission and 1g/kg on Day 3 of admission

957 block 2 (14 decks)

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