Cirrhosis

Question 0

CBC

Answer 0

Anemia
Leukoenia or leukocytosis
Thrombocytopenia

Question 1

Ingestigation

Answer 1

Liver function test
Hypoalbuminemia
Prolonged bleeding time
CBC
Electrolytes

Question 2

Electrolytes

Answer 2

Hyponatremia: Na lost in the third space
Hypokalemia: due to aldosterone
Hypomagnesemia
Hypophosphatemia

Question 3

Liver biopsy

Answer 3

GOLD STANDARD- beware of coagulation

Question 4

Complications

Answer 4

Ascites
Spontaneous bacterial peritonitis
Hepatorenal syndrome
Hepatorenal syndrome
Hepatic encephalopathy
Portal HT
Hematological disorders

Question 5

Ascites- Criteria

Answer 5

1: more than 250 PMNs
2: culture of ascitic fluid

Question 6

Ascites- tx

Answer 6

Albumin + Paracentesis is the best management
Transjugular intrahepatic portosystemic shunt (TIPS)
Liver transplantation

Question 7

Hepatorenal syndrome

Answer 7

Hyponatremia
Elevated BUN + creratinine (>1.5mg/dL)
Elevated liver enzyme
No diuresis with volume expansion (1.5L of saline)

Question 8

Hepatorenal syndrome- tx

Answer 8

Molecular adsorbent recirculating system (MARS)- a modified dialysis method that selectively removes water-bound and albumin-bound toxins
TIPS

Question 9

Hepatic encephaopathy

Answer 9

Complex neuro-psychiatric syndrome
UMN manifestations- spasticity, hyperreflexia, Babinski signs, flapping tremors, fetor hepaticus
**Triphasic waves- Stage I-III of mental status
Delta activity; pts is comatose/ stage IV; no asterixis

Question 10

Hepatic encephalopathy- tx

Answer 10

Restriction of dietary proteins (source of ammonia)
Control of GI bleeding with magnesium citrate
Lactulose (acidifies/ ionize ammonia and causes osmotic diarrhea)
Zinc (needed for urea cycle)
Sodium benzoate or ornithine aspartate (lower ammonia level)

Question 11

Esophageal varices- tx

Answer 11

Fresh frozen plasma
Octreotide/ somatostatin
Endoscopic intervention;
-Banding (lower overall morbidity and mortality than sclerotherapy
-Sclerotherapy (injection of ethanolamine or tetradecyl sulfate)
Balloon tamponade- temporary fix. If pharmacologic and endoscopic means fail. High rebleeding rate.
TIPS (shunt to lower BP)

Question 12

Esophageal varices- prevention of first bleed

Answer 12

Do endoscopy every year
If large varices- give beta blockers
Prophylactic banding

Question 13

Esophageal varices- prevention of rebleed

Answer 13

Beta-blocker or nitrates

TIPS

Question 14

Hepatopulmonary syndrome- investigation

Answer 14

Arterial blood gases (ABG): hypoxemia
Contrast enhanced echo: pulmonary vascular dilation
Ventilation-perfusion lung scan: confirms the diagnosis

Question 15

Hepatopulmonary syndrome- tx

Answer 15

IV methylene blue increase oxygenation by inhibiting nitric oxide- induced vasodilation
Liver transplantation