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PDAT2 > 19 - Cirrhosis > Flashcards

19 - Cirrhosis Flashcards

1
Q

Liver Functions

A

You can NOT live w/o a functioning liver

Metabolizes / Stores nutrients

Synthesizes Molecules (such as cloting factors)

Breaks down Toxins

Participates in the immune sytem

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2
Q

Number 1 cause of cirrhosis?

A

ALCOHOL

Damages liver by causing fatty infiltrates = Steatosis

Damage varies by amount / duration of use + GENETICS

Heavy Drinking = >2drinks/day for men

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3
Q

Causes of CIRRHOSIS

Except for Viral and Alcoholic

A

NASH = Non-alcoholic Seatohepatisis
common in OBESITY

Primary Biliary Cirrhosis
immune attack on BILE DUCTS

Autoimmune Hepatitis
immune attack on hepatocytes

  • *Hemochromatosis**
  • *iron** overload from over-absorption
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4
Q

Signs & Symptoms of CIRRHOSIS

A

Typically well-compensated, without Signs or symptoms

Onset of complications can be insidious:
Malaise / Fatigue / poor appetite

ESLD = Decompensated Cirrhosis, involves

Jaundice / Ascites / Encephalopathy / Variceal Bleeding

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5
Q

ESLD: SIGNS

A

End stage liver disease, decompensated cirrhosis

Jaundice

Ascites

Caput medusa
snake looking things on abdomin

Spider Angioma

Palmar Erythema
red palms

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6
Q

Viral Causes of Cirrhosis

A

HEP C is MOST common cause for LIVER TRANSPLANT

20-30% will develop Cirrhosis within 20 years

Hep B is more common common in ASIANS

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7
Q

Characteristic LAB VALUES in ESLD

A
  • *HIGH INR & Prolonged Prothrombin Time**
  • reduced synthesis of clotting factors*
  • *Thrombocytopenia**
  • =low platelets, decreased thrombopoetin +* splenomegaly
  • *Low ALBUMIN**
  • poor synthetic function in the liver + poor nutrition*
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8
Q

Child Pugh Classification

GRADES WHAT?

A

Scoring System for ESLD, grading:

Encephalopathy (confusion)

Ascites

Bilirubin (mg/dL)

Albumin (g/dl)

Prothrombin ratio or time

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9
Q

Different Grades for
Child Pugh Classification

A

A = <6
highly survivable

B = 7-9
moderate, 81% 1 year survival , 57% 2-year

Grade C = score >9
severe disease, 45% 1 year survival

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10
Q

MELD** **Classification

A

Model for ESLD
score assess risk of death while awaiting LIVER TRANSPLANT

Exponential formula based on:
INR + Bilirubin

Serum Creatinine / Sodium

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11
Q

Higher the MELD score means what?

A

HIGHER RISK OF DEATH

ALSO

HIGHER ON THE PRIORITY LIST FOR LIVER TRANSPLANT

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12
Q

Portal Vein

(portal hypertention)

A

Collects BLOOD from GI Tract –> LIVER
vein that ENTERS the organ (liver)
FIRST PASS METABOLISM

  • *25%** cardiac output is delivered to the LIVER
  • *66%** of that is via the PORTAL VEIN

1-1.5 L/min

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13
Q

Portal HYPERtension

Caused by what TWO types of resistance?

A

INCREASED Resistance to flow** through **LIVER

  • *Fixed Resistance** = nonreversible
  • *Fibrosis** –> destroys sinusoids –> causes physical blockage

Variable Resistance = reversible
Caused by vasoconstrictors such as endothelin in liver

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14
Q

Portal HYPERtension

has INCREASED blood flow due to what?

A

INCREASED Blood Flow** through the **PORTAL VEIN

Vasodilation of splanchnic circulation
NO2 + Prostaglandins + TNF-alpha

Expanded Plasma Volume
Due to INCREASED sodium retention

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15
Q

How does CIRRHOSIS result in PORTAL HYPERTENSION?

A

INCREASED Intrahepatic RESISTANCE
INCREASED Portal blood flow
V
V
V
INCREASED PORTAL PRESSURE = Portal HYPERtension

OHMS LAW
Pressure = Resistance X Flow

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16
Q

How to Measure portal hypertension?

HVPG / WHVP / FHVP

A

HVPG = Hepatic Venous Pressure Gradient

  • *HVPG = WHVP - FHVP**
  • *HVPG > 5mmHG = PORTAL HYPERTENTION**

WHVP = Wedged hepatic venous pressure
= Hepatic sinusoid pressure

FHVP = Free hepatic venous pressure
= Hepatic OUTFLOW pressure

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17
Q

How does

PORTAL HYPERTENSION lead to VARICEAL HEMORRHAGE?

Complications of Cirrhosis

A

Portal HT -> DILATION of collateral vessels
giving alternate routes of systemic curculation to:

Rectal / Splenic Veins

Paraumbilical Veins -> Caput Medusa

Intrinsic veins of esophagus –> VARICES

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18
Q

Esophageal Varices

A

Portal HT –> alternate routes of circulation

–> blood to the ESOPHAGUS

= vomitting blood / tarry stools

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19
Q

Screening for varices for people with cirrhosis

And Prevention

A

Endoscopic GRADING of severity
small or large varices (increased risk for bleeding)

if we see LARGE or Tensioned varices then…..

  • *PRIMARY PREVENTION** (prophylaxis)
  • *Actions to prevent a FIRST EVENT**
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20
Q

1st line therapy for Primary Prevention of Varices

and what do these agents do?

Primary Prevention = Actions to prevent a FIRST event

A
  • *NON-Selective Beta Blockers**
  • *B2 blockages** results in:

splanchnic vasoCONSTRICTION,
which decreases portal blood flow + pressure

reduces FIRST incidence of 1st variceal bleed
by about HALF

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21
Q

Non-Selective Beta Blockers

Types & Use

A

Primary Prevention of Varices
NEED to have the Beta-2 action

Propranolol = 20mg BID

Nadolol = 40mg HS

Carvedilol = 3.125mg BID

goal is to REDUCE HVPG < 12mm HG

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22
Q

Propranolol Dose

for Primary Prevention of Varices

A

20mg BID

Non-selective beta blocker

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23
Q

Nadolol Dose

for Primary Prevention of Varices

A

40 mg at Bedtime

Non-selective Beta Blocker

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24
Q

Carvedilol Dose

for Primary Prevention of Varices

A

3.125 mg** **BID

Non-Selective Beta Blocker

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25
Q

Signs and SYMPTOMS of UPPER GI BLEED

Acute Variceal Bleeding

A

Weakness / Fatigue / Dizziness

HEMATEMESIS
blood in VOMIT

MELENA
DARK + tarry stools

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26
Q

Treatment for Acute Variceal Bleeding​

A
  • *Medical Procedures:**
  • *Band Ligation** + Sclerotherapy + Baloon tamponade

Pharmacologic Therapy

Octreotide

Vasopressin

27
Q

Band Ligation

A

Treatment for Acute Variceal Bleeding​

Endoscopic placement of a elastic band around the varix

Tissue necrosis –> variceal obliteration

28
Q

Sclerotherapy

A
  • *Treatment for Acute Variceal Bleeding​**
  • not done so often anymore*

Injection of sclerosing agent into the varis

induces thrombosis + scarring

29
Q

Balloon Tamponade

A

LAST RESORT Treatment for Variceal Bleeding​

Baloons compress varices

HIGH RATE of REBLEEDING

“HAIL MARY”

30
Q

Drug of Choice for

Treatment for Acute Variceal Bleeding​​

A
  • *OCTREOTIDE**
  • ONLY AN ADJUNCT to Medical treatment*

Long-Acting Somatostatin Analogue
selective splanchnic vasoCONSTRICTOR

reduces portal pressure

50 mcg IV LoadingDose –> 50mcg/hr IV

31
Q

Octreotide

Dose / Indication / ADR

A

Pharmaceutic Drug of choice for Variceal Bleeding
splanhnic vasoconstrictor

  • *50 mcg IV LoadingDose
  • -> 50mcg/hr IV**

~72 hours to reduce re-bleeding risk

Risk of hypo/hyper_glycemia_ + _bradycardia_ +
headache / abcramp

32
Q

Vasopressin

Dose / Indication / ADR

A

2ndary Treatment for Acute Variceal Bleeding
not preferrable to OCTREOTIDE

0.4 - 0.8 units/min
a very HIGH dose

RARELY USED TOO MANY ADR
Risk of ISCHEMIA / hyponatremia

33
Q

Alternate Medication Therapy for

Variceal Bleeding

A

ANTIBIOTIC THERAPY

Reduces mortality in patients with ELSD who have an
upper GI bleed (includes variceal bleed)

  • *CEFTRIAXONE**
  • *1g IV QD**
  • *LEVOFLOXACIN**
  • *500mg QD** (IV or PO)

for 5-7 days

34
Q

Antibiotic Therapies for Variceal Bleeding

Drug Names / Doses / Duration

A
  • *Ceftriaxone_ _IV**
  • *1g qd**
  • *Levofloxacin**
  • *500mg QD** (IV or PO)

5 to 7 days

35
Q

Intrahepatic SHUNT

TIPS

A

Used as SALVAGE THERAPY
when endoscopic intervention + drug therapy FAIL

“total hail mary”

Transjugular Intrahepatic Portosytemic SHUNT

Creates a shunt between portal & hepatic veins

36
Q

1st & 2nd line Treatment for

Primary Prevention of Variceal Bleed

A

NON-selective BETA BLOCKER
Propranolol / Nadolol / Carvedalol

2nd = Band Ligation

37
Q

1st & 2nd line Treatment for

ACUTE VARICEAL BLEED

A

OCTREOTIDE + Band Ligation
50 mcg IV LoadingDose

TIPS
SHUNT

38
Q

1st & 2nd line Treatment for

SECONDARY PREVENTION
(prevent a RE-BLEED)

A

Beta Blocker + Band Ligation
Propranolol / Nadalol / Carvedilol

TIPS** or **TRANSPLANT
Shunt

39
Q

Non-Pharmacological Treatment for

ASCITIS

A

_Restrict SODIUM INTAKE_
<2 grams / day

without sodium restriction diuretics will FAIL

only restrict FLUIDS
if HYPONATREMIA is present

1 - 1.5 L / day , Na <125

40
Q

Medical Treatment of ASCITES

A

LVP = large volume PARACENTESIS of >3Liters
simply removing the ascites, usually with albumin infusions

SHUNTS = TIPS
used in refractory ascites, that need FREQUENT LVP

41
Q

Pharmacologic Treatment of Ascites

A

DIURETICS

Furosemide / Spironolactone / Amiloride

Goal is to decrease ascites
without hypoVOLEMIA

42
Q

Spironolactone

Indication / Dose / ADR

A

Treatment of ASCITES

Potassium Sparing Diuretic
competetive inhibitor of aldosterone

100 mg QD –> max 400mg/day

ADR:
ELEVATED K / hypoNATREMIA / _gynecomastia_

43
Q

Furosemide

Indication / Dose / ADR

A

CO-Treatment for ASCITES

Loop Diuretic

Ratio of 100mg Spironolactone
to each 40mg qd of Furosemide

less efficacious ALONE vs w/ spironolactone for CIRRHOSIS

hypoKalemia = counteracted by spironolactone

44
Q

Amiloride

Indication / Dose / ADR

A

Used when patient
does NOT want to take Spironolactone due to GYNOCOMASTIA

Not first line therapy, for ASCITES

  • *10 mg Amiloride**
  • instead of 100mg spironolactone*
45
Q

How does Spontaneous Bacterial Peritonitis occur?
SBP
Complication of Cirrhosis

A

Bacteria overgrowth due to poor immune system
V
Bacteria TRANSLOCATE across the intestinal wall
V
ESCAPED bacteria enter the ascites fluid
SBP

46
Q

How is SBP Diagnosed?

Spontaneous Bacterial Peritonites

A

PMN > 250/mm^3
= Polymorphonuclear Cell Count

if a Positive Cuture:
treat for GNR (gram negative rods)

47
Q

Cefotaxime

Dose / Indication

A

Treatment for SBP = Spontaneous Bacterial Peritonitis
or CN SBP = Culture Negative SBP
or Symptomatic MNB = Monomicrobial non-neutrocytic Bacteracscites

2 gm Q8H for 5 days
Large volume albumin infusion reduces mortality

48
Q

Ceftriaxone

Dose / Indication

A

Treatment for SBP = Spontaneous Bacterial Peritonitis
or CN SBP = Culture Negative SBP
or Symptomatic MNB = Monomicrobial non-neutrocytic Bacteracscites

2 gm Q2-4H for 5 days
Large volume albumin infusion reduces mortality

49
Q

Quinolone IV = Levofloxacin

Dose / Indication

A

Used to replace Cefotaxime for TRUE PCN ALLERGY
for SBP / CN SBP / Symptomatic MNB

500 mg Q2H for 5 days

Large volume albumin infusion reduces mortality

50
Q

First line treatment for HE
Hepatic Encephalopathy

A

LACTULOSE
non-absorbably disaccharide

Metabolized by gut bacteria,

  • *OSMOTIC LAXATIVE**
  • *Cathartic effect –> decreases TOXIN LOAD in COLON**
51
Q

Lactulose for ACUTE Encephalopathy

Dose / ADR

A

ACUTE ENCEPHALOPATHY = HE

  • *30-45 mL** PO or via NG Tube
  • *every 2 hours** until DIARRHEA
  • -> titrate to 2-4 soft stools a day

or can be given as an enema

52
Q

Lactulose for CHRONIC Encephalopathy

Dose / Indication

A

Titrate dose to
MAINTAIN 2-4 SOFT STOOLS/DAY

dose is mainly based on DIARRHEA / BOWEL MOVEMENT

Often requires 30mL 2-4 times per day

53
Q

Second / Third Line Treatment for HE

A

RIFAXIMIN
Antibiotic, EXPENSIVE, but NOT systemically absorbed
550mg po BID

3rd Line: Metronidazole / Neomycin
not used due to systemic absorption

250mg po BID / 500-1000mg po BID

54
Q

SAAG

What is SAAG, and what does it Indicate?

A

Serum-Ascites Albumin Gradient

SAAG = [Serum Albumin] - [Ascites Albumin]

>1.1

= likely ASCITES / Liver Disease

55
Q

What BACTERIA is shown in SBP?

A

SBP is typically monomicrobial

E.Coli + KLEBSIELLA are MOST COMMON

(PMN > 250/mm3 in the ascites fluid)

Streptococcus / Enterococcus
is also common

56
Q

Treatment for a Positive Culture of SBP?

A

With PMN > 250/mm3

treat ASAP for:
GNR** + **STREP
(Gram Negative Rods)

Tailor the antibiotics to culture

Usually a 3rd generation Antibiotic:
Cefotaxime / Ceftriaxone / quinolone

57
Q

Treatment for Negative Culture (culture Negative) CN SBP?

A

With PMN > 250/mm3

treat EMPIRICALLY for:
GNR + STREP
(Gram Negative Rods)

Tailor the antibiotics to culture

Usually a 3rd generation Antibiotic:
Cefotaxime / Ceftriaxone / quinolone

58
Q

Treatment for MNB?
monomicrobrial NON-Neutrocytic Bacterascitis?

A
  • *PMN is LESS THAN < 250/mm3 **
  • *+**
  • *POSITIVE CULTURE**

ONLY TREAT IF SYMPTOMATIC

Treat according to the culture
Usually a 3rd generation Antibiotic:
Cefotaxime / Ceftriaxone / quinolone

59
Q

What is SECONDARY Bacterial Peritonitis?

How do you treat it?

A

Cultures show PMN > 250/mm3 + MULTIPLE POSITIVE CULTURES
Typically from a BOWEL perforation

REQUIRES SURGICAL INTERVENTION

+

Broad Spectrum Antibiotics
that cover GNR / Anaerobes / Enterococcus

60
Q

What medications are used for SBP Prophylaxis?

And what is the Indication?

A

Previous episode of SBP (70% chance of recurrence)
OR
Ascites protein < 1.5 g/dL + Child-Pugh > 9 OR Renal Dysfunction

Treat INDEFINITELY with:
Ciprofloxacin 500mg QD
(Norfloxacin 400mg QD)
Bactrim DS QD

61
Q

What is Hepatorenal Syndome?
HRS

Complication of Cirrhosis

A

RENAL FAILURE linked to portal hypertention

Caused by altered hemodynamics

Splanchic + Systemic vasoDILATION

Arterial underfilling –> poor renal perfusion

activation of renin-angiotensin-aldosterone system / SNS / ADH

  • *VASOCONSTRICTION** @ KIDNEY
  • decreased GFR*
62
Q

What is Type 2 HRS?

A

Hepatorenal Syndrome

  • *GRADUAL INCREASE** in
  • *SCr** to >1.5

may need KINDEY TRANSPLANT

63
Q

What is TYPE 1 HRS?

A

HepatoRenal Syndrome, ESLD with….

SCr DOUBLES to > 2.5

in less than 2 weeks
kidney transplant is NOT required

NOT:
hypovolemia / intrinsic kidney disease / obstruction
due to nephrotoxic drugs / due to SHOCK

64
Q

Type 1 HRS TREATMENT

A

Combination treatment = HRS COCKTAIL

Octreotide** + **Midodrine** + **Albumin

100-200mcg SQ q8hr / 7.5-12.5mg PO q8hr / 40g per day

decrease vasocontriction x2 / increase blood volume

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