Cirrhosis Flashcards
Complications of cirrhosis
Ascites Portal HTN Variceal bleeding Spontaneous bacterial peritonitis (SBP) Hepatic encephalopathy Hepatorenal syndrome (HRS)
Ascites physical exam findings
Full, tense, bulging abdomen
Tests to determine ascites
Abdominal ultrasound, abdominal paracentesis
Features of abdominal ultrasound
Tells whether or not there’s fluid there, but doesn’t tell you how it got there
What is abdominal paracentesis?
Sticking a needle into the peritoneum in the abdominal cavity and draining the fluid
Features of abdominal paracentesis
It removes fluid so it’s not only therapeutic, it’s also good for diagnostic purposes
What SAAG value is indicative of portal HTN?
> 1.1
Can you still do abdominal paracentesis on a patient who has low platelets and high PT/INR?
Yes!
Treatment of ascites (like main first line treatment)
Sodium restriction (2g/day) 40mg of Lasix paired with 100mg of spironolactone
What happens if diuresis from Lasix and spironolactone don’t work?
Add on midodrine
What if midodrine doesn’t work?
Large volume paracentesis (4-8L every 2 weeks) and give IV 25% albumin
What happens if large volume paracentesis and the IV 25% albumin don’t work?
TIPS procedure
What does the TIPS procedure do?
Place a stent that connects the portal vein to the hepatic vein via a shunt so it bypasses the liver and disease
Where else is a TIPS procedure used in cirrhosis besides ascites?
Refractory variceal bleeding
Side effect of TIPS
Increased chance of hepatic encephalopathy
What treatments do you NOT use in ascites?
Fluid restriction and thiazide-type diuretics
Treating portal HTN prevents what?
Variceal bleeding
How does portal HTN happen?
Difference in pressure between the portal and hepatic veins
Untreated portal HTN can lead to what?
Variceal bleeding
Goal of portal HTN treatment
Prevent variceal enlargement and bleeding
The downside to portal HTN treatment
Hasn’t been proven to PREVENT varices from developing
Diagnosis of portal HTN
Upper endoscopy to look for varices present
Portal HTN treatment
If varices are present, treat with non-selective beta blockers!
Non-selective beta-blockers
Propranolol, nadolol, carvedilol
Non-selective beta-blocker with greatest antihypertensive effects
Carvedilol
How to titrate non-selective beta-blockers in cirrhosis
Titrate the dose up until a patient’s resting HR is ~60bpm
When to hold a beta-blocker dose
Hypotension
Decompensated states
Refractory ascites
Patients with SBP
Variceal bleeding is a risk factor for what?
SBP
Variceal bleeding treatment: supportive care measures
IV fluids, packed RBCs, supplemental O2
Variceal bleeding treatment: octreotide route of administration
IV bolus, then as an infusion
Variceal bleeding treatment: EVL
Rubberbanding the varices and squeezing them off
Best results of EVL are when it’s combined with what?
Octreotide
Variceal bleeding treatment: SBP prophy
7-day course of a 3rd generation cephalosporin
If EVL and octreotide don’t work, what can you consider?
TIPS
After variceal bleeding stabilizes, what do you do next?
Worry about portal HTN; start non-selective beta-blockers
Causes of SBP
K. pneumoniae, E. coli
SBP signs and symptoms
Fever, malaise, elevated WBC, pain and tenderness in abdomen
SBP diagnosis methods
Use paracentesis to see WBCs and/or bacterial organisms in fluid
Can also do bacterial culture
Problems with bacterial culture in SBP diagnosis
Not everyone will come back with positive cultures (but we still treat them regardless which is a good thing)
Absolute PMN count for SBP diagnosis and treatment
≥250/mm3
SBP treatment: third generation cephalosporins
Cefotaxime, ceftriaxone
Who is IV albumin recommended for?
Anyone with SCr >1, BUN >30, bilirubin >4 mg/dl
SBP prophylaxis: patients with acute variceal bleeding
7-day course of IV ABX (ceftriaxone)
Treatment for indefinite SBP prophy
Cipro 250-500mg QD
Bactrim DS QD
How does hepatic encephalopathy occur?
Accumulation of toxins from decreased hepatic function and portal systemic shunting
What do you measure in HE?
Ammonia levels
What do you use to monitor a patient’s progress with HE?
MENTAL STATUS! NOT AMMONIA LEVELS
HE treatment
Taper down or D/C meds if possible (opioids and benzos)
Protein restrict
Lactulose
Rifaximin as add-on to lactulose
Lactulose dosing for acute HE
25ml PO q1-2h until ≥2 loose/watery stools
Retention enema: retina for 1 hour, give q6-12h
Lactulose dosing for HE prevention
Same dosing as acute HE, then lactulose 15-60ml q6-12h, titrate to 2-3 soft bowel movements/day
Lactulose ADEs
N/V, cramping, diarrhea
Rifaximin MoA
Reduce bacteria in gut that produce ammonia
Rifaximin dosing
Acute: 400mg PO q8h
Maintenance: 550mg PO BID
How does hepatorenal syndrome (HRS) occur?
Splanchnic vasodilation secondary to portal HTN –> reduced effective circulating volume/intravascular volume –> reduced renal perfusion –> kidneys die off
Diagnosis of HRS
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
HRS treatment
IV norepinephrine and IV albumin 1g/kg/day
Liver transplant is also an option
Response to HRS treatment
SCr decrease to <1.5mg/dl or return within 0.3mg/dl of baseline over a max of 2 weeks
What happens if after 4 days of therapy, the SCr remains the same or rises above pre-treatment levels for HRS treatment?
D/C
Hallmark sign of liver failure
Increased PT/INR and bilirubin
What is Child-Pugh grading used for?
Dosing adjustments
What is the MELD score used for?
Prognosticate patients with cirrhosis and how severe it is
Mainly used for liver transplant considerations (high score=higher on the transplant list)
What does the MELD score take into account?
SCr
PK/PD: decreased liver blood flow
Impacts high first-pass effects- drug with lots of removal will have more systemic circulation
Drugs affected by decreased liver blood flow
Propranolol, morphine, carvedilol- decrease dose to compensate!
PK/PD: loss of hepatocyte function
Decreased metabolic capacity by phase I metabolism with the CYP enzymes
How to compensate for loss of hepatocyte function
Use agents that undergo phase II metabolism
PK/PD: decreased albumin production
Drugs that are heavily protein bound will be more unbound and will have more therapeutic effects
Reduce dose to compensate if needed!
PK/PD: reduced renal function in the setting of increased Scr
Reduced renal perfusion, reduced intravascular volume, may have HRS
Monitor renal function
PK/PD: increased therapeutic response
Increased permeability of BBB in cirrhosis (drugs like opioids and benzos)
Monitor therapeutic effects and decrease dose to compensate
SBP treatment: IV option
IV albumin 25% 1.5g/kg on day 1 and 1g/kg on day 3
SBP treatment: ABX in patients who have a PCN allergy
Ciprofloxacin (or any other 3rd generation cephalosporin)
How long is SBP treatment?
5 days
How much IV albumin do you give when drawing out large volumes of fluid during large volume paracentesis?
If drawing out >5L, give 8g IV 25% albumin for every L of fluid removed
