Cirrhosis Flashcards
Decompensated cirrhosis
Ascites
GI bleed
HE
Hepatorenal syndrome
Acute on chronic liver failure
Chronic liver disease (+/-cirrhosis) with elevated bili and INR, may have organ failure
Ascites causes
SAAG>1.1 = Portal hypertension
Cirrhosis
Massive liver mets
Right heart failure
SAAG<1.1 = No portal hypertension
Peritoneal carcinomatosis
TB
Dialysis
Pancreatic disease
Ascites evaluation
History
Liver risk factors (alcohol, metabolic, viral, family history)
Heart, haem, thyroid, autoimmune, pancreatic, malignancy
Travel
Exam
Shifting dullness
Abdo tenderness
Pleural effusion
Stigmata CLD
Heart failure
Lymphadenopathy (malignancy/infection)
Sarcopenia (malnutrition)
Thyroid
FBC, EUC, LFT, Coags, Albumin
Urinalysis, UACR
Abdo ultrasound doppler
Ascitic tap
Ascitic tap tests
SAAG (not recurrent)
PMN count
Cytology
Culture
Protein
Glucose
LDH (not recurrent)
Amylase (not recurrent)
Ascites treatment
Low salt diet
Cease NSAIDs, ACEi, ARB, α 1 blocker
Avoid nephrotoxins
Grade 1 (ultrasound only): no treatment
Grade 2 (moderate abdo distension):
Diuretics (limit to 0.5-1kg per day)
-Spironactone 100mg daily up to 400mg daily. Less in renal disease. Slow titration (3 days)
-Frusemide 40mg daily up to 160mg daily. More in renal disease
Grade 3: Tense ascites
Large volume paracentesis. Albumin cover if over 5L. Albumin 6-8g/L removed. INR >5 or plts <50 not contraindicated
Consider TIPs
Spontaneous bacterial peritonitis evaluation and management
Abdominal pain and tenderness
Often no symptoms. Suspect in hospitalised cirrhotic with ascites
Suspect in AKI, HE, jaundice
Ascitic tap:
SBP confirmed with PMN count >250
Not present if no infective signs, PMN count <250 with positive culture
Give ceftriaxone for 5-7 days. Start as early as possible.
Consider tazocin if nosocomial infection
Give albumin (1-1.5g/kg per day)
Cease beta blocker if hypotensive
SBP prophylaxis
Secondary prophylaxis:
All patients with prior SBP
Ciprofloxacin or Bactrim
Primary prophylaxis:
All patients with UGIB receive ceftriaxone
Consider oral abx in low protein ascites, advanced cirrhosis or severe renal disease
Hyponatraemia in cirrhosis management
Mild: 126-135
Moderate: 120-125
Severe: <120
Clinical manifestations: Fatigue, confusion, cramps, headache, ataxia, seizure
Typically hypervolaemic (worsening haemodynamics)
-Fluid restrict
-Correct hypokalaemia
-Cease beta blockers, diuretics and anti-hypertensives
-Consider midodrine with MAP >80
-Consider vaptans
Hypovolaemic: Diuretics, laxatives, poor oral intake
-Cease diuretics and laxatives
-Volume expand with 5% albumin (or Hartmanns)
Euvolaemic: SIADH, mediations, hypothyroid, adrenal insufficiency
-Address cause
Severe and symptomatic:
-ICU
-Albumin 20% at 1g/kg per day
-Hypertonic saline
-Dialysis
Limit Na correction to 5mmol per day
Hepatic hydrothorax
Ascites associated pleural effusion. Typically unilateral (and right sided) but can be any pattern.
High 90 mortality (>75%)
Managed with fluid restriction and diuretics. Consider LVP and thoracocentesis with albumin
Recurrent managed with TIPS and liver transplant
Hepatorenal evaluation and management
Advanced liver failure (acute or chronic) with acute kidney injury. Alternative causes (pre renal, renal , post renal) excluded. Not responsive to albumin resuscitation. Low urine Na. No or minimal proteinuria and haematuria.
Cease anti hypertensives and beta blockers
Consider noradrenaline in ICU
Terlipressin + albumin
Octreotide + midodrine + albumin
Consider dialysis and liver transplant
Aim to keep MAP >80
Cirrhosis causes
Most common:
Chronic viral
Alcoholic liver disease
Haemochromatosis
NAFLD
Cirrhosis clinical manifestations
Symptoms
-anorexia
-weight loss
-fatigue
-pruritus
-cramps
-confusion
-sleep disturbance
-GI bleeding
-diarrhoea
Signs
-hypotension
-jaundice, pale stool, dark urine
-ascites
-caput medusa
-encephalopathy
-spider naevi
-gynacomastia
-splenomegaly
-palmar erythema
-clubbing
-asterixis
Cirrhosis diagnosis
Consider clinical evidence, lab and imaging together
Bloods
-moderate ALT and AST rise, AST usually higher
-mild ALP and GGT rise
-normal bili, rising with progression
-hypoalbuminaemia
-prolonged PT
-hyponatraemia
-thrombocytopenia, anaemia
-leukopaenia/neutropaenia in hypersplenism
Imaging
-ultrasound: high sensitivity /specificity, portal hypertension, varices
-CT and MRI rarely indicated. Not significantly better than ultrasound
APRI
-AST/platelet
-most useful for excluding significant fibrosis
Elastography
-can diagnose cirrhosis and differentiate grades of fibrosis
Biopsy is gold standard but rarely used
Variceal bleeding management
Ensure safe airway
Ensure adequate oxygenation/ventilation
Blood transfusion
-aim Hb >70 for most
-aim Hb >80 if CAD
-aim Hb >100 if acute MI
Withhold anticoagulants and anti platelets
Consider reversal in life threatening bleed, significantly raised INR, or want to avoid MTP
INR/PT minimally useful
Give ceftriaxone
Give terlipressin or octreotide
Withhold antihypertensives if hypotensive
Keep NBM
Doppler abdo ultrasound to exclude portal vein thrombosis
Endoscopy within 24hrs
Consider balloon tamponade
