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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
**Signs and SYMPTOMS of UPPER GI BLEED** **Acute Variceal Bleeding**
**Weakness / Fatigue / Dizziness** **_HEMATEMESIS_** blood in _VOMIT_ **_MELENA_** DARK + tarry _stools_
26
**Treatment for Acute Variceal Bleeding​**
* *_Medical Procedures:_** * *Band Ligation** + Sclerotherapy + Baloon tamponade **_Pharmacologic Therapy_** **Octreotide** **Vasopressin**
27
**Band Ligation**
**_Treatment for Acute Variceal Bleeding​_** Endoscopic placement of a **elastic band** around the **varix** Tissue necrosis --\> **variceal obliteration**
28
**Sclerotherapy**
* *_Treatment for Acute Variceal Bleeding​_** * not done so often anymore* **Injection** of **sclerosing agent** into the varis induces **thrombosis + scarring**
29
**Balloon Tamponade**
**_LAST RESORT Treatment for Variceal Bleeding​_** Baloons **compress varices** HIGH RATE of **REBLEEDING** "HAIL MARY"
30
**Drug of Choice for** **Treatment for Acute Variceal Bleeding​​**
* *_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
**_Octreotide_** **Dose / Indication / ADR**
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
**Vasopressin** **Dose / Indication / ADR**
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
**Alternate Medication Therapy for** **Variceal Bleeding**
**_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
**Antibiotic Therapies for** **Variceal Bleeding** ## Footnote **Drug Names / Doses / Duration**
* *_Ceftriaxone**_ _**IV_** * *1g qd** * *_Levofloxacin_** * *500mg QD** (IV or PO) **_5 to 7 days_**
35
**_Intrahepatic SHUNT_** ## Footnote **TIPS**
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
**1st & 2nd line Treatment for** **Primary Prevention of Variceal Bleed**
**_NON-selective BETA BLOCKER_** Propranolol / Nadolol / Carvedalol 2nd = **Band Ligation**
37
**1st & 2nd line Treatment for** **ACUTE VARICEAL BLEED**
**_OCTREOTIDE + Band Ligation_** 50 mcg IV LoadingDose **_TIPS_** SHUNT
38
**1st & 2nd line Treatment for** **SECONDARY PREVENTION** (*prevent a RE-BLEED)*
**_Beta Blocker + Band Ligation_** Propranolol / Nadalol / Carvedilol **_TIPS**_ or _**TRANSPLANT_** Shunt
39
**Non-Pharmacological Treatment for** **ASCITIS**
_*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
**Medical Treatment of ASCITES**
**_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
**Pharmacologic Treatment of Ascites**
**_DIURETICS_** **Furosemide / Spironolactone / Amiloride** Goal is to *decrease ascites* ***_without hypoVOLEMIA_***
42
**_Spironolactone_** **Indication / Dose / ADR**
Treatment of **_ASCITES_** **Potassium Sparing Diuretic** competetive inhibitor of aldosterone **_100 mg QD_** --\> max 400mg/day ADR: ELEVATED **K** / *hypoNATREMIA / **_gynecomastia_***
43
**Furosemide** Indication / Dose / ADR
**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
**Amiloride** Indication / Dose / ADR
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
How does **_Spontaneous Bacterial Peritonitis_** occur? **SBP** Complication of Cirrhosis
**Bacteria overgrowth** due to **poor immune system** V **Bacteria TRANSLOCATE** across the intestinal wall V **ESCAPED** bacteria enter the **ascites fluid** SBP
46
**How is SBP Diagnosed?** **Spontaneous Bacterial Peritonites**
**_PMN_** \> **250/mm^3** = **Polymorphonuclear Cell Count** if a **Positive Cuture**: **treat for** **GNR** (gram negative rods)
47
**Cefotaxime** Dose / Indication
Treatment for **_SBP_** = Spontaneous Bacterial Peritonitis or **CN SBP** = Culture Negative SBP or **Symptomatic MNB** = Monomicrobial non-neutrocytic Bacteracscites **_2 gm Q8H_** fo**r 5 days** Large volume **albumin infusion** reduces mortality
48
**Ceftriaxone** Dose / Indication
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
**Quinolone IV = Levofloxacin** **Dose / Indication**
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
**First line treatment for HE** Hepatic Encephalopathy
**_LACTULOSE_** non-absorbably disaccharide Metabolized by **gut bacteria**, * *OSMOTIC LAXATIVE** * *Cathartic effect --\> decreases TOXIN LOAD in COLON**
51
**Lactulose for ACUTE Encephalopathy** **Dose / ADR**
_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
**Lactulose for CHRONIC Encephalopathy** **Dose / Indication**
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
**Second / Third Line Treatment for HE**
**_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
**SAAG** What is SAAG, and what does it **Indicate?**
**S**erum-**A**scites **A**lbumin **G**radient **SAAG** = **[Serum Albumin]** - **[Ascites Albumin]** **\>1.1** = likely **ASCITES / Liver Disease**
55
What **BACTERIA** is shown in **SBP?**
SBP is typically **_monomicrobial_** **E.Coli** + **KLEBSIELLA** are MOST COMMON (PMN \> 250/mm3 in the ascites fluid) ***Streptococcus / Enterococcus** is also common*
56
Treatment for a **Positive Culture** of **SBP**?
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
Treatment for **Negative Culture** **(culture Negative) CN SBP**?
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
Treatment for **MNB?** **monomicrobrial NON-Neutrocytic Bacterascitis?**
* *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
What is **SECONDARY Bacterial Peritonitis?** ## Footnote **How do you treat it?**
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
What **medications** are used for **SBP Prophylaxis**? And what is the **Indication?**
**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
What is **Hepatorenal Syndome?** **HRS** Complication of Cirrhosis
**_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
What is **Type 2 HRS?**
Hepatorenal Syndrome * *_GRADUAL INCREASE_** in * *_SCr_** to **\>1.5** ***_may need KINDEY TRANSPLANT_***
63
What is **TYPE 1 HRS?**
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
**Type 1 HRS TREATMENT**
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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