Case 3: Cirrhosis

Question 1

Diagnoses:

Answer 1

-Pruritis -COPD -Alcohol abuse -Tobacco abuse -Cirrhosis -Hepatitis C infection -Anemia -CKD 3b

Question 2

Pruritis: Etiology -Can develop in patients who have ________ due to any cause -List Ex’s

Answer 2

**cholestasis -Intrahepatic cholestasis of pregnancy -Primary sclerosing cholangitis -Malignant biliary tract obstruction -Chronic viral hepatitis -Nonmalignant biliary tract obstruction -Cirrhosis

Question 3

Pruritis: Pathology -elevated levels of ____ acids in the skin act as pruritogens -Pruritis is also associated with higher serum ____ levels and autotaxin activity

Answer 3

-Incompletely understood -**Elevated levels of bile acids in the skin can act as pruritogens -Lysophosphatidic acid and autotaxin–>Phospholipid formed by action of autotaxin –Studies show patients with cholestatic pruritis had much higher serum LPA levels and autotaxin activity –Injection of LPA induced scratch responses in mice

Question 4

Pruritis: Pathology: _______ ______ levels are elvated in Patients with chronic liver disease

Answer 4

Endogenous opioid

Question 5

Cholestatic Pruritis: tx -The following treatments can be used if the Pt doesn’t have which 2 conditions: -1st line tx ? -2nd line ? -3rd line ?

Answer 5

-If the Pt doesn’t have intrahepatic cholestasis of pregnancy or primary biliary cholangitis: Bile acid sequestrant 1st line (Ie: **cholestyramine (Questran) or colestipol (Colestid) –80-85% of patients respond 2nd: Try rifampin (Rifampicin) 3rd: opioid antagonist Ie: naltrexone (Vivitrol) If above fails, try sertraline or phenobarbital

Question 6

MELD Score=

Answer 6

Model for End-Stage Liver Disease

Question 7

What labs are included in MELD score calculation?

Answer 7

Uses serum bilirubin, creatinine, INR, and whether a patient has recently had dialysis to predict 3-month survival -2016: Serum sodium added (MELDNa score)

Question 8

Higher MELD score indicates ______

Answer 8

worse liver dysfunction and ↑ mortality risk

Question 9

MELD score is used to prioritize Pts awaiting ____

Answer 9

liver transplant

Question 10

Cirrhosis: complications?

Answer 10

-Variceal hemorrhage -Ascites -Spontaneous Bacterial Peritonitis -Hepatic encephalopathy -hepatic hydrothorax -Hepatocellular Carcinoma -hepatopulmonary Syndrome

Question 11

Variceal Hemorrhage: management?

Answer 11

-EGD screening/band ligation -Nonselective beta blocker (propranolol, nadolol)

Question 12

Ascites: tx?

Answer 12

-Diuretics: Spironolactone/furosemide (100:40 ratio) -+/- Paracentesis (albumin replacement after large volume paracenteses if > 4-5 L are removed) -Sodium restriction

Question 13

Spontaneous Bacterial Peritonitis: tx?

Answer 13

Empiric antibiotics: -Cefotaxime -Prophylactic antibiotics for patients who have previously had SBP

Question 14

Hepatic encephalopathy: tx?

Answer 14

Lactulose/lactitol or rifaximin

Question 15

Hepatic hydrothorax: tx?

Answer 15

Diuretics, sodium restriction

Question 16

Hepatocellular carcinoma: tx?

Answer 16

-Surgical resection -Liver transplant

Question 17

Hepatopulmonary syndrome: tx?

Answer 17

-Liver transplantation -Long-term oxygen therapy

Question 18

Screening tool used for alcohol abuse

Answer 18

CAGE: Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink

Question 19

Screening used for HCC

Answer 19

serial US

Question 20

Screening used for hepatic encephalopathy

Answer 20

More detailed neuro exam & testing

Question 21

Cirrhosis: Follow-up/possible referrals

Answer 21

-GI: Hepatology –Cirrhosis & Hep C -Nephrology -Psychology/Psychiatry -Smoking Cessation -Alcohol Rehab, AA or other support group

Question 22

Counseling/Patient Education

Answer 22

-Smoking cessation -Alcohol cessation -Hep C status -Hx IVDA -Possible complications of cirrhosis -Medications to avoid: –Hepatic dosing –Renal dosing

Question 23

COPD: tx

Answer 23

Tiotropium (Spiriva) & a short-acting rescue inhaler

Question 24

Cirrhosis: tx

Answer 24

Diuretics ± paracentesis for ascites/edema management

Question 25

Hep C: tx

Answer 25

Consideration for antiviral treatment

Question 26

Pruritus: tx

Answer 26

Cholestyramine (Questran) or other agent

Question 27

Tobacco abuse: tx

Answer 27

Nicotine patch, gum, other quit aid

Question 28

What is the hallmark serologic marker for acute infection of Hep B?

Answer 28

HBsAg

Question 29

When should postvaccination testing be completed for Hep B?

Answer 29

2 months after 3rd vaccine dose

Question 30

Serology: Susceptible to Hep B

Answer 30

• HBsAg -neg
• anti-HBc -neg
• anti-HBs -neg

Question 31

Serology: Immune due to natural infection

Answer 31

• HBsAg -neg
• anti-HBc -pos
• anti-HBs -pos

Question 32

Serology: Immune due to Hep B vacc?

Answer 32

• HBsAg -neg
• anti-HBc -neg
• anti-HBs -pos

Question 33

Serology: Acute vs Chronic

Answer 33

Acute

• HBsAg - pos
• anti-HBc - pos
• IgM anti-HBc - pos
• anti-HBs - neg

Chronic

• HBsAg - pos
• anti-HBc - pos
• IgM anti-HBc - neg
• anti-HBs - neg

Question 34

What are the 4 possible interpretations for:

• HBsAg - neg
• anti-HBc - pos
• anti-HBs - neg

Answer 34

1. Recovering from acute HBV infxn
2. Distantly immune & test not sensitive enough to detect low level of anti-HBs
3. Susceptible w/ false positive anti-HBc
4. Undetectable level of HBsAg present in serum & person is actually chronically infected