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GI, liver, kidney > Cirrhosis > Flashcards

Cirrhosis Flashcards

1
Q

Which AI hep is more severe

A

Type 2

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2
Q

Stages of cirrhosis

A

Stage 1
Stage 2 - varices, no ascites
Decompesnation event (HVPG >12mmHg)
Stage 3 - bleeding
Stage 4 - first non bleeding decompensation - ascites, HE, jaundice
Stgae 5 - second decompensation

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3
Q

How does portal HPTN occur

A

→ Liver failure +splanchic vasodilation → increased portal blood inflow - increased portal pressure → varices → bleeding

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4
Q

Cirrhosis effects on systemic circulation

A
  • Vasodilation
  • Hypotension
  • Increased plasma volume
  • Increased cardiac index

→ hypovolaemia→ RAAS + Na retention → ascites

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5
Q

What are signs of decompensation in cirrhosis

A

Jaundice
Increasing ascites
Hepatic encephalopathy
Renal impariment/hypovolaemia
Signs of spesis

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6
Q

What can precipitate a decompensation in liver disease

A

GI bleeding
Infection/sepsis
Alcohol Drugs - opiates, NSAIDs
HCC
Portal vein thrombosis
Dehydration
Contipation - encephalopathy

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7
Q

How analyse asciic fluid and when done

A

Paracentesisi
New ascites, cirrhotic patient with ascites in hospital

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8
Q

What is SAAG

A

Albumin in serum:ascites

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9
Q

What does a SAAG >11 suggest

A

ascites due to portal HPTN

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10
Q

Causes of ascites SAAG >11

A

Portal HPTN
Cardiac failure
Portal vein thrombosis
Hypothyroidism

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11
Q

Causes of ascites where SAAG <11

A

Pertionneal carcinomastosis
Peritonneal TB
Panceratitis
Bowel perforation
Nephrotic syndrome

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12
Q

What get in SBP

A

Fever, abdo pain, renal impairment or asymptomatic

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13
Q

What find in ascitic tap in SBP

A

Polymorphonucear cells >250m3
Neutrophils 0.25x109

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14
Q

Treatment SBP

A

Anitbiotics - test for sensitivities - co-amoxilav or ciprofloxacin

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15
Q

Ascites management

A

Na restrict, diuretics #
TIPS
Large volume paracentesis
Liver transplant

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16
Q

Criteria for diagnosis of hepatorenal syndrome exclusion

A

Cirrhosis, ALF
Criteria for fialing kidneys urine output/creatinine >50%
No full or partial response after 2 days diuretic withdrawal + volume expansion with albumin
Absence of shock
No current or recent nephrotoxic drugs
Absence of parenchymal disease - proteinuria, haematuria, urinary biomarkers
FeNa <0.2% (renal vasoconstriction)

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17
Q

Kidney crtieria for hepatorenal syndrome - class 1

A

Absolute increase in sCR >0.3 mg/dL in 48 hrs
Urinary output <0.5ml/kg BW >6 hrs
% increase in sCR >50% using last available value of outpatient sCr within 3 months

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18
Q

Resus for a variceal bleed

A

Intubation consider
High flow O2
IV access
Blood transfusion
Antibiotics
Terlipressin/somatostatin
If fail -> balloon
tamponade
If unstable immediate gastroccopy

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19
Q

After resus management of variceal bleed

A

Gastroscopy within 24 hours - separate oesophageal vs gastric origin

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20
Q

Oesophageal variceal bleed management

A

Band ligation
Success -> sedonary prophylaxis after 5 days

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21
Q

Secondary prophylaxis varcies oesophageal

A

VBL + non selective beta blcker

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22
Q

Who do a TIPS within 72 hrs of bleed in (after haemostasois)

A

Childs pugh B + active bleed
Childs pugh C + ,14 - 1b, grade B

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23
Q

Gastric variceals treatment

A

Cryanoacrylate injection or trombin
Consider SBB
TIPS if large or multiple barices

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24
Q

First line for rebleed varices

A

Salvage TIPS
Balloon tamponae until can do a TIPS

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25
Alternative to TIPS
Balloon occulded retrograde transvenus obliteration or surgical shunt
26
How monitor if no varices on endoscopy
Re endosocpe in 2-3 years
27
What do if Grade I varices on endoscopy
Re-endsocope in 1 year
28
What do if grade II or III varices - or red signs
Non selective beta blocker If intolerant -> band ligation Cryanocylate injection if needed
29
When do splenectomy or splenic artery embolisation in cirrhosis
L sided portal HPTN or splenic vein thrombosis
30
How does vasopressin work
increases peripheral resistance, decreases splanchic blood flow Has to be given IV
31
Antibiotic options for GI bleed
Cephalosporin, quinolones, betalactam, carbepenam
32
When refer for TIPS
After failure of second therapy for varices
33
What NSBB given for variceal bleed prophylaxis
Propanolol 40mg 2 x daily Also carvediol, nadolol
34
When discontinue NSBB in cirrhosis
SBP, renal impairment, hypotnesion Offer VBL if CI
35
When is there no need to repeat endoscopy in cirrhosis
Already on NSBB and no findings
36
What do if TIPS not feasible in CP A/B
Shunt surgery
37
What is a red sign on varices on endoscopy
evidence of bleeding already or high risk bleed
38
Grading of varices
1 - narrow, flatten easily with air 2 - broader and flatten with difficulty or dont 3- 4-
39
Why does cirrhosis cause HE
Increased gut dervied toxins in blood noramlly cleared by liver stay in as blood is shunted away from passing through + liver cant process as well
40
How to tell if HE is acute or chronic
Cerbral oedema - acute liver failure
41
Triggers for HE
Decompensating events Infection GI bleed Electrolyte disturbance Constipation Sedative drugs
42
Mangement of Hepatic encephalotpathy
Treat underlying cause Oral lacutalose - aim 2-3 stools/day Phosphate enemas Rifazamin
43
When give rifaxamin in HE
if persistent />1 admission
44
Grade 1 HE
Mild confusion, euphira, aniety, depression, reversed sleep syndrome, slurred speech
45
Grade 2 HE
Drowsy and lethargi, gross deficits in mentla tasks, moderate confusion
46
Grdae III vs IV HE
III - somnolent but arousable, severe confusion, inability to perform mental tasks IV - coma (IVa) with (IVb) without response to painful stimuli
47
Screening for malnutrition in cirrhosis when do
BMI <18.5 Childs pugh score C
48
How assess nutritonal status in cirrhosis
Muscle mass - CT, DEEA, US mUSCLE fucntion - hand grip Global physical performance - time up and 6 min walk test Educate patient on imporatnce - - 30 kcal/BW/day, 1.5-2g protein/BW
49
Areas assessed in childs pugh score
Encephalopathy (none, minimal, coma) AScites (absent, controlled, refractory) Bilirubin <34, - , >51 Albumin >35, -, <28 PT <4, -, .6
50
What is the UKELD score
Calculation of need for transplant in UK Include bilirubin, INR, creatinine, Na
51
Surveillance for HCC in cirrhotic/high risk patients
every 6 monts US and alpha fetoprotein
52
Chemoprevention strategies HCC
Antivirals antiinflams Antifirbtoics Metabloci disease treat Molecular targeted therapies
53
Treatment options for early HCC
Ablation, resection, transplant >5 year survival
54
Treatment for intermediate HCC
Chemoembolisation Preserved liverfunction but unresectable
55
Treatment for advanced HCC
Liver function, portal/intrahepatic spread Systemic therapy PS1-2 10 month survival
56
What is terminal stage HCC
Not transferable End stage liver function PS3-4
57
When is surgery possible with HCC
Grade 0 - single lesion <2cm early stgae - solitary OR 2-3 nodules <3cm If solitary -> resection If transplant candidate, transplant If neither -> ablation
58
UK liver transplant indications - score level cirrhosis, HCC
Chronic liver failure - UKELD >49 HCC up to 5 tumours <3cm or single up to 5/7cm if stable Acute liver failure
59
How does variceal bleeding present
Haematemesis - blood vomit, bright red or coffee ground Melaena - black tarry dark stools Severe hypotnesion
60
Clotting agents may need transfusing in varcieal bleed
correct clotting: FFP, vitamin K, platelet transfusions
61
Do endosopy or terlipressin and antibiotics first in variceal beed
Terlipressina nd quinolones first
62
Common complication of TIPS
Uraemia-> excerbation of hepatic encephalopathy
63
63
Risk factors for HCC
CIRRHOSIS - hepatitis, alcohol, haemoachromatosis, PBC Alpha 1 antitrypsin deficiency Glycogen storage disease Hereditary tyrosinosis Aflatoxin Drugs - COCP, anabolic steroids Porphyria cutanea tarda Male DM, metbaolic syndrome
64
Presentation of HCC
Decompesnation of liver disease Jaundice, ascites, RUQ pain, hepatomegaly, pruritis, splenomegaly Presents late
65
Referral crtieria HCC
2 week wait US if upper abdo mass - hepatomegaly
66
Medication for HCC?
Sorafenib - multikinase inhibitor
67
What groups screen with US + AFP
patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis men with liver cirrhosis secondary to alcohol

GI, liver, kidney (50 decks)

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