Case 3: Cirrhosis Flashcards
Diagnoses:
-Pruritis -COPD -Alcohol abuse -Tobacco abuse -Cirrhosis -Hepatitis C infection -Anemia -CKD 3b
Pruritis: Etiology -Can develop in patients who have ________ due to any cause -List Ex’s
**cholestasis -Intrahepatic cholestasis of pregnancy -Primary sclerosing cholangitis -Malignant biliary tract obstruction -Chronic viral hepatitis -Nonmalignant biliary tract obstruction -Cirrhosis
Pruritis: Pathology -elevated levels of ____ acids in the skin act as pruritogens -Pruritis is also associated with higher serum ____ levels and autotaxin activity
-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
Pruritis: Pathology: _______ ______ levels are elvated in Patients with chronic liver disease
Endogenous opioid
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 ?
-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
MELD Score=
Model for End-Stage Liver Disease
What labs are included in MELD score calculation?
Uses serum bilirubin, creatinine, INR, and whether a patient has recently had dialysis to predict 3-month survival -2016: Serum sodium added (MELDNa score)
Higher MELD score indicates ______
worse liver dysfunction and ↑ mortality risk
MELD score is used to prioritize Pts awaiting ____
liver transplant
Cirrhosis: complications?
-Variceal hemorrhage -Ascites -Spontaneous Bacterial Peritonitis -Hepatic encephalopathy -hepatic hydrothorax -Hepatocellular Carcinoma -hepatopulmonary Syndrome
Variceal Hemorrhage: management?
-EGD screening/band ligation -Nonselective beta blocker (propranolol, nadolol)
Ascites: tx?
-Diuretics: Spironolactone/furosemide (100:40 ratio) -+/- Paracentesis (albumin replacement after large volume paracenteses if > 4-5 L are removed) -Sodium restriction
Spontaneous Bacterial Peritonitis: tx?
Empiric antibiotics: -Cefotaxime -Prophylactic antibiotics for patients who have previously had SBP
Hepatic encephalopathy: tx?
Lactulose/lactitol or rifaximin
Hepatic hydrothorax: tx?
Diuretics, sodium restriction
Hepatocellular carcinoma: tx?
-Surgical resection -Liver transplant
Hepatopulmonary syndrome: tx?
-Liver transplantation -Long-term oxygen therapy
Screening tool used for alcohol abuse
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
Screening used for HCC
serial US
Screening used for hepatic encephalopathy
More detailed neuro exam & testing
Cirrhosis: Follow-up/possible referrals
-GI: Hepatology –Cirrhosis & Hep C -Nephrology -Psychology/Psychiatry -Smoking Cessation -Alcohol Rehab, AA or other support group
Counseling/Patient Education
-Smoking cessation -Alcohol cessation -Hep C status -Hx IVDA -Possible complications of cirrhosis -Medications to avoid: –Hepatic dosing –Renal dosing
COPD: tx
Tiotropium (Spiriva) & a short-acting rescue inhaler
Cirrhosis: tx
Diuretics ± paracentesis for ascites/edema management
Hep C: tx
Consideration for antiviral treatment
Pruritus: tx
Cholestyramine (Questran) or other agent
Tobacco abuse: tx
Nicotine patch, gum, other quit aid
What is the hallmark serologic marker for acute infection of Hep B?
HBsAg
When should postvaccination testing be completed for Hep B?
2 months after 3rd vaccine dose
Serology: Susceptible to Hep B
- HBsAg -neg
- anti-HBc -neg
- anti-HBs -neg
Serology: Immune due to natural infection
- HBsAg -neg
- anti-HBc -pos
- anti-HBs -pos
Serology: Immune due to Hep B vacc?
- HBsAg -neg
- anti-HBc -neg
- anti-HBs -pos
Serology: Acute vs Chronic
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
What are the 4 possible interpretations for:
- HBsAg - neg
- anti-HBc - pos
- anti-HBs - neg
- Recovering from acute HBV infxn
- Distantly immune & test not sensitive enough to detect low level of anti-HBs
- Susceptible w/ false positive anti-HBc
- Undetectable level of HBsAg present in serum & person is actually chronically infected
