Alcohol-Induced Liver Disease Exam 3

Question 1

S/S of Cirrhosis

Answer 1

• Ascites
• Jaundice/Icterus
• Clay colored stools
• Cola colored urine
• Palmar erythema
• Altered mental status
• Asterixis
• Abdominal pain
• Spider angiomas

Question 2

S/S of Esophageal Varices / Variceal Bleed (EVB)

Answer 2

• Severe hematemesis
• Melena
• Hematochezia

Question 3

S/S of Ascites

Answer 3

• Protruding abdomen
• Pitting edema
• Positive fluid wave
• Shifting dullness
• Abdominal pain / discomfort

Question 4

S/S of Spontaneous Bacterial Peritonitis (SBP)

Answer 4

• Fever
• Leukocytosis
• Diffuse abdominal pain with rebound tenderness
• Altered mental status
• Worsening HE
• Hypotension
• Ascites

Question 5

S/S of Hepatic Encephalopathy (HE)

Answer 5

• Altered mental status

- Asterixis

Question 6

In cirrhosis, what are the labs that are indicative of obstruction?

Answer 6

• ↑ Bilirubin (or damage)
• ↑ Alk phos
• ↑ GGT
• If both alk phos and GGT are high, suggest a hepatic source

Question 7

What are the labs that you can see in Alcohol liver disease?

Answer 7

• AST at least twice ALT (individual elevations typically less than 500 IU/L)
• ↑ bilirubin

Question 8

What does the Maddrey discriminant function (MDF) score predict?

Answer 8

Predicts short-term prognosis

Question 9

Maddrey discriminant function (MDF) score and when to treat

Answer 9

• Score ≥ 32 indicates poor prognosis

- pharmacologic treatment if MDF ≥ 32

Question 10

What are the treatment options based on the MDF score?

Answer 10

• Prednisolone 40 mg daily x 28 days followed by a taper (preferred)
• Pentoxifylline 400 mg TID x 28 days (alternative if steroid contraindications)

Question 11

contraindications for prednisolone

Answer 11

• active GI bleed

- infection

Question 12

What are the goals for treating ascites?

Answer 12

Make patient comfortable - will not completely eliminate ascites

Question 13

Nonpharmacologic treatment for ascites

Answer 13

• Alcohol abstinence
• Restrict sodium to < 2g/day
• Fluid restriction if sodium is less than 120-125 mEq/L
• For tense ascites or refractory ascites -> Paracentesis
• If removing > 5 liters, give 6-8 g albumin per liter of fluid removed to maintain oncotic pressure

Question 14

Pharmacologic treatment for ascites

Answer 14

• Spironolactone (Aldactone ®) 100 mg/day PO
• Furosemide (Lasix ®) 40 mg/day PO
• Maintain 100 mg: 40 mg ratio for normal potassium levels (normokalemia)
• Max dose: spironolactone 400 mg + furosemide 160 mg

Question 15

monitoring parameters for ascites

Answer 15

• blood pressure
• electrolyte imbalances
• renal function
• gynecomastia
• fluid balance
• mental status
• daily weight
• ins and outs

Question 16

When would you hold diuretic therapy for ascites?

Answer 16

• Uncontrolled or recurrent encephalopathy (if diuretic is the cause of HE)
• Sodium < 120 mmol/L
• Serum creatinine > 2 mg/dL (acute change in baseline renal function)

Question 17

What is the recommended weight loss for a patient with ascites?

Answer 17

• 0.5 kg/day in those without peripheral edema

- 1 kg/day in those with edema

Question 18

lactulose MOA

Answer 18

“ion trapping”; NH3 -> NH4+ -> excreted in the stool

Question 19

octreotide MOA

Answer 19

somatostatin analogue that inhibits release of vasodilatory peptides; local vasoconstrictive effect on splanchnic vasculature

Question 20

propranolol MOA

Answer 20

↓ portal pressure by reducing portal venous inflow; ↓ cardiac output via beta 1; splanchnic vasoconstriction (↓ blood flow to portal vein) via beta 2

Question 21

spironolactone MOA

Answer 21

inhibits the action of aldosterone in the distal convoluted tubule; K+ sparing

Question 22

furosemide MOA

Answer 22

inhibits reabsorption of Na and Cl in the ascending loop of Henle and distal renal tubule

Question 23

midodrine MOA

Answer 23

alpha agonist; vasoconstrictor

Question 24

rifaximin MOA

Answer 24

↓ urease-containing bacteria in the intestine  ↓ the production of NH3 from proteins and amino acids; minimal systemic absorption

Question 25

spontaneous bacterial peritonitis diagnosis

Answer 25

• When a patient presents with clinical s/sx, assume it is SBP until proven otherwise
• Polymorphonuclear Leukocytes (PMN) ≥ 250 cells/mm^3
• Ascitic fluid culture may be negative- continue to treat if PMN ≥ 250 cells/mm3

Question 26

treatment for spontaneous bacterial peritonitis

Answer 26

• Start antibiotic therapy when PMN ≥ 250 cells/mm3 or convincing s/sx
• Cefotaxime 2 g IV q 8 h or ceftriaxone 1 g BID x 5 days
• Start albumin therapy if SCr > 1 mg/dL, BUN > 30 mg/dL, or t. bili > 4 mg/dL
• Decreases mortality and renal impairment
• 1.5 g/kg once within 6 hours of detection of SBP and 1 g/kg on day three

Question 27

prophylaxis for spontaneous bacterial peritonitis

Answer 27

• Fluoroquinolones (ciprofloxacin) or sulfamethoxazole / trimethoprim (SMZ/TMP) daily
• Daily dosing preferred to minimize development of resistant organisms

Question 28

hepatorenal syndrome treatment: non-ICU

Answer 28

• Midodrine 7.5-12.5 mg TID (vasoconstrictor)

- PLUS Octreotide 100-200 mcg SQ TID (inhibits vasodilators)

Question 29

hepatorenal syndrome treatment: ICU

Answer 29

Norepinephrine titrated continuous infusion

Question 30

hepatorenal syndrome treatment: all

Answer 30

• Albumin 1 g/kg (day 1), then 20-40 g daily

- Discontinue nephrotoxins, supply gentle hydration, avoid sudden shifts in intravascular volume

Question 31

anticoagulation strategy for an ALD / cirrhosis patient

Answer 31

• Liver disease patients are not “auto-anticoagulated” with elevated INRs
• LMWH is the prevention and treatment of choice for VTE

Question 32

5 dosing recommendation considerations due to changes in pharmacokinetic parameters and drug metabolism in ALD / cirrhosis

Answer 32

• Monitor response to therapy
• Consider clinical outcomes of accumulation
• Reduce dose and titrate to response
• Avoid drugs metabolized by Phase I reactions
• Use alternative agents that are renally eliminated