Cirrhosis

Question 0

Macronodular liver

Answer 0

Viral hepatitis

Question 1

Micronodular liver

Answer 1

Alcohol cause

Question 2

Most common cause of liver disease in U.S.

Answer 2

NASH: non alc steato hepatitis

Question 3

Hidden epidemic and increasing prevalence (more severe)

Answer 3

Hep C cirrhosis

Question 4

Liver pathology

Answer 4

1) fat accumulation
2) inflammation
3) fibrosis

Lose fenestrae and activate stellate cells and deposit collagen

Fatty liver consequence of obesity

Question 5

Physical exam of cirrhosis

Answer 5

Vascular spiders
Palmar erythema
Jaundice
Ascites

Small liver
Splenomegaly
Colloid shift to bone marrow

Question 6

Cirrhosis labs

Answer 6

INR >1.3
High bilirubin >3
Low Albumin < 3

Low platelet - earliest sign of cirrhosis
AST/ALT > 1

Question 7

Decompensated cirrhosis

Answer 7

Presence of variceal hemorrhage
Ascites
Encephalopathy
Jaundice

Medial survival 1.6 years
Need transplant

Question 8

Prevent variceal hemorrhage

Prophylaxis

Answer 8

Non-selective propranolol (20BID)
, nadolol (20QD)
B1 heart, B2 splanchnic vasoconstriction

Block renin & Decrease aldosterone and salt retention

Endoscopic variceal ligation -
For small varices w/ risk factors
And large varices

Question 9

Acute hemorrhage

Answer 9

1)Octreotide (50mcg)

Somatostatin
Vasopressin (ADH)

Ceftriaxone, ciprofloxacin

Question 10

Cirrhosis ascites

Answer 10

SAAG > 1.1

EtOH, Na restriction

Spironolactone (aldosterone antagonist) & Furosemide combo
100:40 qAM

LVParacentesis if refractory

Question 11

Transplant

Answer 11

Meld score > 15 (22)

Question 12

Liver

Answer 12

Produces bile, albumin
Convert glucose into glycogen
Ammonia to urea
Control infections

First pass processing

Question 13

Obesity Altered adipocytokines

1st hit - fat accumulation

Answer 13

Leptin resistance (less satiety)
Decrease adiponectin (worsen insulin resistance)

Question 14

Inflammation - 2nd hit

Answer 14

Increase TNF alpha, IL 6

Question 15

NAFLD

Answer 15

Weight loss and exercise

Orlistat

Question 16

Ethanol

Answer 16

Can be complicated if impaired ADH and ALDH, CYP2E1

Acetaldehyde buildup = flush

GGT best indicator of excessive alcohol consumption

Question 17

Spontaneous Bacterial Peritonitis

Answer 17

Complication of ascites

Cefotaxime - 3rd gen
Oxfloxacin - block DNA synthesis
For 5 days

Long term - norfloxacin, Bactrim prophylaxis for those with 1 episode of SBP

Question 18

Hepatic encephalopathy

Answer 18

Lactulose to trap ammonia an stimulate bowel movement

Acidify colon and catharsis inhibit urease producing bacteria

Can use with rifaxamin

Decrease protein intake

Question 19

Cirrhosis GABA-ergic tone

Answer 19

Flumazenil (BDZ antagonist)

Question 20

Drugs that cause cirrhosis (hepatotoxic)

Answer 20

Methotrexate

Amiodarone

Question 21

PK considerations of cirrhosis

Answer 21

Reduced albumin protein binding

Ascites increase Vd