25 - Complications of Liver Disease

Question 1

Child-Turcotte-Pugh Score

Answer 1

old way to rank mortality/severity of chronic liver disease - included albumin, bili, INR, ascites, encephalopathy
the subjective components led to misuse for transplant eligibility purposes

Question 2

MELD

Answer 2

model of end stage liver disease
formula based on bilirubin, INR, and creatinine - no subjective component
predicts mortality at 90 d (score >40 = 100% mortality)
used for liver transplant allocation

Question 3

situations in where there are exceptions for the MELD formula

Answer 3

tumors, biliary sepsis, lung dz, metabolic dz, bleeding

Question 4

leading cause of hypervolemic hyponatremia

Answer 4

cirrhosis

Question 5

relationship between hyponatremia in liver disease and mortality

Answer 5

for a given MELD score, the more severe your hyponatremia is the worse your prognosis is

Question 6

general prognosis of ascites

Answer 6

50% mortality in 2 yrs

Question 7

information from ascitic fluid analysis

Answer 7

use urine dipstick to check quickly for leukocytosis
suspect spontaneous bacterial peritonitis if PMNs > 250/ml
cultures are sent for these, but often dont come back pos
check albumin as well

Question 8

SAAG

Answer 8

serum-ascites albumin gradient
simply subtract ascites albumin conc from serum conc
if >1.1 g/dL, 97% chance of portal HTN

Question 9

controlling Na/water balance in liver dz pts

Answer 9

if urinary excretion of Na is good, can just restrict dietary Na. only restrict water if serum sodium is <120-5 mmol/L

Question 10

diuretics from chronic liver dz

Answer 10

spironolactone + furosemide

Question 11

how do you distinguish refractory ascites from noncompliance w/ Na restriction?

Answer 11

look at 24 hr Na excretion - if >78 mmol they are noncompliant
if <78, refractory

Question 12

options for refractory ascites tx

Answer 12

serial paracentesis
TIPS
liver transplant
perinovenous shunt

Question 13

TIPS

Answer 13

transjuluar intrahepatic porto-systemic shunt

basically bypasses liver to solve portal HTN sx, but in exchange a large amount of blood is not processed by liver

Question 14

2 types of hepatorenal syndrome

Answer 14

1 - rapidly progressive, doubling serum Cr to >2.5 mg/dL or 50% reduction in Cr clearance to <20ml/min in less than 2 wks
2 - slow course

Question 15

tx of hepatorenal syndrome

Answer 15

triple therapy - albumin, octreotide, midodrine (alpha agonist)
TIPS
liver transplant

Question 16

typical causative agents of spontaneous bacterial peritonitis

Answer 16

E coli, klebsiella, pneumococcus

Question 17

what tx beside abx should be given to pts w/ spontaneous bacterial peritonitis?

Answer 17

albumin - helps dec mortality

Question 18

how bad does the hepato-venous pressure gradient have to be to form varices? for them to bleed?

Answer 18

form at >10 mmHg

bleed at >12 (usually around 20)

Question 19

most common bleeding varix site

Answer 19

esophagus

Question 20

drugs that help keep varices from bleeding

Answer 20

beta blockers, octreotide

Question 21

tx options for hepatic encephalopathy

Answer 21

lactulose - works in gut as laxative
rifamixin
neomycin
metronidazole (not currently FDA approved for HE)

(abx are used to reduce ammonia producing enteric bacteria)