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PHM 604- Nutrition and Cirrhosis > Cirrhosis > Flashcards

Cirrhosis Flashcards

1
Q

Complications of cirrhosis

A 
Ascites
Portal HTN
Variceal bleeding
Spontaneous bacterial peritonitis (SBP)
Hepatic encephalopathy
Hepatorenal syndrome (HRS)
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2
Q

Ascites physical exam findings

A

Full, tense, bulging abdomen

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3
Q

Tests to determine ascites

A

Abdominal ultrasound, abdominal paracentesis

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4
Q

Features of abdominal ultrasound

A

Tells whether or not there’s fluid there, but doesn’t tell you how it got there

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5
Q

What is abdominal paracentesis?

A

Sticking a needle into the peritoneum in the abdominal cavity and draining the fluid

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6
Q

Features of abdominal paracentesis

A

It removes fluid so it’s not only therapeutic, it’s also good for diagnostic purposes

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7
Q

What SAAG value is indicative of portal HTN?

A

> 1.1

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8
Q

Can you still do abdominal paracentesis on a patient who has low platelets and high PT/INR?

A

Yes!

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9
Q

Treatment of ascites (like main first line treatment)

A 
Sodium restriction (2g/day)
40mg of Lasix paired with 100mg of spironolactone
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10
Q

What happens if diuresis from Lasix and spironolactone don’t work?

A

Add on midodrine

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11
Q

What if midodrine doesn’t work?

A

Large volume paracentesis (4-8L every 2 weeks) and give IV 25% albumin

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12
Q

What happens if large volume paracentesis and the IV 25% albumin don’t work?

A

TIPS procedure

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13
Q

What does the TIPS procedure do?

A

Place a stent that connects the portal vein to the hepatic vein via a shunt so it bypasses the liver and disease

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14
Q

Where else is a TIPS procedure used in cirrhosis besides ascites?

A

Refractory variceal bleeding

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15
Q

Side effect of TIPS

A

Increased chance of hepatic encephalopathy

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16
Q

What treatments do you NOT use in ascites?

A

Fluid restriction and thiazide-type diuretics

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17
Q

Treating portal HTN prevents what?

A

Variceal bleeding

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18
Q

How does portal HTN happen?

A

Difference in pressure between the portal and hepatic veins

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19
Q

Untreated portal HTN can lead to what?

A

Variceal bleeding

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20
Q

Goal of portal HTN treatment

A

Prevent variceal enlargement and bleeding

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21
Q

The downside to portal HTN treatment

A

Hasn’t been proven to PREVENT varices from developing

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22
Q

Diagnosis of portal HTN

A

Upper endoscopy to look for varices present

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23
Q

Portal HTN treatment

A

If varices are present, treat with non-selective beta blockers!

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24
Q

Non-selective beta-blockers

A

Propranolol, nadolol, carvedilol

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25
Q

Non-selective beta-blocker with greatest antihypertensive effects

A

Carvedilol

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26
Q

How to titrate non-selective beta-blockers in cirrhosis

A

Titrate the dose up until a patient’s resting HR is ~60bpm

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27
Q

When to hold a beta-blocker dose

A

Hypotension
Decompensated states
Refractory ascites
Patients with SBP

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28
Q

Variceal bleeding is a risk factor for what?

A

SBP

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29
Q

Variceal bleeding treatment: supportive care measures

A

IV fluids, packed RBCs, supplemental O2

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30
Q

Variceal bleeding treatment: octreotide route of administration

A

IV bolus, then as an infusion

31
Q

Variceal bleeding treatment: EVL

A

Rubberbanding the varices and squeezing them off

32
Q

Best results of EVL are when it’s combined with what?

A

Octreotide

33
Q

Variceal bleeding treatment: SBP prophy

A

7-day course of a 3rd generation cephalosporin

34
Q

If EVL and octreotide don’t work, what can you consider?

A

TIPS

35
Q

After variceal bleeding stabilizes, what do you do next?

A

Worry about portal HTN; start non-selective beta-blockers

36
Q

Causes of SBP

A

K. pneumoniae, E. coli

37
Q

SBP signs and symptoms

A

Fever, malaise, elevated WBC, pain and tenderness in abdomen

38
Q

SBP diagnosis methods

A

Use paracentesis to see WBCs and/or bacterial organisms in fluid

Can also do bacterial culture

39
Q

Problems with bacterial culture in SBP diagnosis

A

Not everyone will come back with positive cultures (but we still treat them regardless which is a good thing)

40
Q

Absolute PMN count for SBP diagnosis and treatment

A

≥250/mm3

41
Q

SBP treatment: third generation cephalosporins

A

Cefotaxime, ceftriaxone

42
Q

Who is IV albumin recommended for?

A

Anyone with SCr >1, BUN >30, bilirubin >4 mg/dl

43
Q

SBP prophylaxis: patients with acute variceal bleeding

A

7-day course of IV ABX (ceftriaxone)

44
Q

Treatment for indefinite SBP prophy

A

Cipro 250-500mg QD

Bactrim DS QD

45
Q

How does hepatic encephalopathy occur?

A

Accumulation of toxins from decreased hepatic function and portal systemic shunting

46
Q

What do you measure in HE?

A

Ammonia levels

47
Q

What do you use to monitor a patient’s progress with HE?

A

MENTAL STATUS! NOT AMMONIA LEVELS

48
Q

HE treatment

A

Taper down or D/C meds if possible (opioids and benzos)
Protein restrict
Lactulose
Rifaximin as add-on to lactulose

49
Q

Lactulose dosing for acute HE

A

25ml PO q1-2h until ≥2 loose/watery stools

Retention enema: retina for 1 hour, give q6-12h

50
Q

Lactulose dosing for HE prevention

A

Same dosing as acute HE, then lactulose 15-60ml q6-12h, titrate to 2-3 soft bowel movements/day

51
Q

Lactulose ADEs

A

N/V, cramping, diarrhea

52
Q

Rifaximin MoA

A

Reduce bacteria in gut that produce ammonia

53
Q

Rifaximin dosing

A

Acute: 400mg PO q8h
Maintenance: 550mg PO BID

54
Q

How does hepatorenal syndrome (HRS) occur?

A

Splanchnic vasodilation secondary to portal HTN –> reduced effective circulating volume/intravascular volume –> reduced renal perfusion –> kidneys die off

55
Q

Diagnosis of HRS

A

Cirrhosis with ascites

SCr ≥0.3mg/dl in 48 hours or ≥50% increase in baseline in last 7 days

No improvement in SCr after 2 days of diuretic D/C and IV albumin at 1g/kg/day

56
Q

HRS treatment

A

IV norepinephrine and IV albumin 1g/kg/day

Liver transplant is also an option

57
Q

Response to HRS treatment

A

SCr decrease to <1.5mg/dl or return within 0.3mg/dl of baseline over a max of 2 weeks

58
Q

What happens if after 4 days of therapy, the SCr remains the same or rises above pre-treatment levels for HRS treatment?

A

D/C

59
Q

Hallmark sign of liver failure

A

Increased PT/INR and bilirubin

60
Q

What is Child-Pugh grading used for?

A

Dosing adjustments

61
Q

What is the MELD score used for?

A

Prognosticate patients with cirrhosis and how severe it is

Mainly used for liver transplant considerations (high score=higher on the transplant list)

62
Q

What does the MELD score take into account?

A

SCr

63
Q

PK/PD: decreased liver blood flow

A

Impacts high first-pass effects- drug with lots of removal will have more systemic circulation

64
Q

Drugs affected by decreased liver blood flow

A

Propranolol, morphine, carvedilol- decrease dose to compensate!

65
Q

PK/PD: loss of hepatocyte function

A

Decreased metabolic capacity by phase I metabolism with the CYP enzymes

66
Q

How to compensate for loss of hepatocyte function

A

Use agents that undergo phase II metabolism

67
Q

PK/PD: decreased albumin production

A

Drugs that are heavily protein bound will be more unbound and will have more therapeutic effects

Reduce dose to compensate if needed!

68
Q

PK/PD: reduced renal function in the setting of increased Scr

A

Reduced renal perfusion, reduced intravascular volume, may have HRS

Monitor renal function

69
Q

PK/PD: increased therapeutic response

A

Increased permeability of BBB in cirrhosis (drugs like opioids and benzos)

Monitor therapeutic effects and decrease dose to compensate

70
Q

SBP treatment: IV option

A

IV albumin 25% 1.5g/kg on day 1 and 1g/kg on day 3

71
Q

SBP treatment: ABX in patients who have a PCN allergy

A

Ciprofloxacin (or any other 3rd generation cephalosporin)

72
Q

How long is SBP treatment?

A

5 days

73
Q

How much IV albumin do you give when drawing out large volumes of fluid during large volume paracentesis?

A

If drawing out >5L, give 8g IV 25% albumin for every L of fluid removed

PHM 604- Nutrition and Cirrhosis (6 decks)

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