Alcohol-Induced Liver Disease Exam 3 Flashcards

1
Q

S/S of Cirrhosis

A
  • Ascites
  • Jaundice/Icterus
  • Clay colored stools
  • Cola colored urine
  • Palmar erythema
  • Altered mental status
  • Asterixis
  • Abdominal pain
  • Spider angiomas
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2
Q

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

A
  • Severe hematemesis
  • Melena
  • Hematochezia
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3
Q

S/S of Ascites

A
  • Protruding abdomen
  • Pitting edema
  • Positive fluid wave
  • Shifting dullness
  • Abdominal pain / discomfort
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4
Q

S/S of Spontaneous Bacterial Peritonitis (SBP)

A
  • Fever
  • Leukocytosis
  • Diffuse abdominal pain with rebound tenderness
  • Altered mental status
  • Worsening HE
  • Hypotension
  • Ascites
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5
Q

S/S of Hepatic Encephalopathy (HE)

A
  • Altered mental status

- Asterixis

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6
Q

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

A
  • ↑ Bilirubin (or damage)
  • ↑ Alk phos
  • ↑ GGT
  • If both alk phos and GGT are high, suggest a hepatic source
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7
Q

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

A
  • AST at least twice ALT (individual elevations typically less than 500 IU/L)
  • ↑ bilirubin
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8
Q

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

A

Predicts short-term prognosis

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9
Q

Maddrey discriminant function (MDF) score and when to treat

A
  • Score ≥ 32 indicates poor prognosis

- pharmacologic treatment if MDF ≥ 32

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10
Q

What are the treatment options based on the MDF score?

A
  • Prednisolone 40 mg daily x 28 days followed by a taper (preferred)
  • Pentoxifylline 400 mg TID x 28 days (alternative if steroid contraindications)
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11
Q

contraindications for prednisolone

A
  • active GI bleed

- infection

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12
Q

What are the goals for treating ascites?

A

Make patient comfortable - will not completely eliminate ascites

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13
Q

Nonpharmacologic treatment for ascites

A
  • 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
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14
Q

Pharmacologic treatment for ascites

A
  • 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
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15
Q

monitoring parameters for ascites

A
  • blood pressure
  • electrolyte imbalances
  • renal function
  • gynecomastia
  • fluid balance
  • mental status
  • daily weight
  • ins and outs
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16
Q

When would you hold diuretic therapy for ascites?

A
  • 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)
17
Q

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

A
  • 0.5 kg/day in those without peripheral edema

- 1 kg/day in those with edema

18
Q

lactulose MOA

A

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

19
Q

octreotide MOA

A

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

20
Q

propranolol MOA

A

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

21
Q

spironolactone MOA

A

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

22
Q

furosemide MOA

A

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

23
Q

midodrine MOA

A

alpha agonist; vasoconstrictor

24
Q

rifaximin MOA

A

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

25
Q

spontaneous bacterial peritonitis diagnosis

A
  • 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
26
Q

treatment for spontaneous bacterial peritonitis

A
  • 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
27
Q

prophylaxis for spontaneous bacterial peritonitis

A
  • Fluoroquinolones (ciprofloxacin) or sulfamethoxazole / trimethoprim (SMZ/TMP) daily
  • Daily dosing preferred to minimize development of resistant organisms
28
Q

hepatorenal syndrome treatment: non-ICU

A
  • Midodrine 7.5-12.5 mg TID (vasoconstrictor)

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

29
Q

hepatorenal syndrome treatment: ICU

A

Norepinephrine titrated continuous infusion

30
Q

hepatorenal syndrome treatment: all

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

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

31
Q

anticoagulation strategy for an ALD / cirrhosis patient

A
  • Liver disease patients are not “auto-anticoagulated” with elevated INRs
  • LMWH is the prevention and treatment of choice for VTE
32
Q

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

A
  • 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