Cirrhosis Flashcards
What is the gold standard for cirrhosis diagnosis?
Liver biopsy
Is cirrhosis a disease?
No, it is a final common pathway of liver damage
What does cirrhosis result from?
fibrotic changes w/in the hepatic sinusoids and results in changes in the levels of vasodilatory and vasoconstrictor mediators and in increase in blood flow to the splanchnic vasculature
What do the grades rate in cirrhosis?
Degree of liver inflammation
What do the stages rate in cirrhosis?
Degree of fibrosis
What are the effects of portal HTN?
Esophageal varices (hematemesis) Melena (gastrophy) Splenomegaly Dilated abdominal veins (caput medusa) Ascites (more advanced) Rectal varices (hemorrhoids)
What are the effects of liver cell failures?
Coma Fetor hepaticus (breath smells like a freshly opened corpse) Spider nevi Gynecomastia Jaundice Ascites Loss of sexual hair Testicular atrophy Liver "flap" (coarse hand tremor) Bleeding tendency (decreased prothrombin) Anemia (macrocytic, iron deliciency) Ankle edema
What is compensated cirrhosis?
Further substaged by presence of mild mortal HTN or clinically significant portal HTN
Median survival: >12 years
What is decompensated cirrhosis?
Presence of ascites, variceal hemorrhage, and/or hepatic encephalopathy
Median survival: 2 years
What are the potential complications of cirrhosis?
Portal HTN VAriceal bleeding Ascites Spontaneous bacterial peritonitis Hepatic encephalopathy Hepatorenal syndrome Coagulation disorders
What are coagulation disorders
Both pro- and anticoagulant proteins are reduced with a tendency toward hypocoagulability in earlier stages of cirrhosis
Bleeding
Portal vein thrombosis
What are general supportive care for cirrhosis?
Alcohol abstinence is KEY
Vaccinations: HAV, HBV, flu and pneumococcal
TLC (reduce obesity with diet and exercise, smoking cessation, dc coffee)
Statins - evidence they may decrease portal HTN and incidence of HCC
What is portal HTN?
Increased resistance to blood flow in the liver ultimately resulting in the formation of collateral blood vessels (varices) in an attempt to reduce resistance
When do we prophylax for varices?
ALL patients with medium to large varices
What is primary prophylaxis for varices?
Non-selective Beta-blockers
Propranolol - is most common
What do we do if the pt cannot take beta-blockers for prophylaxis of varices?
Endoscopic varcieal ligation
What is the MOA of beta-blockers in variceal bleeds?
Decrease portal venous inflow through B1-adrenergic blockade (decreased CO) and B2-adrenergic blockade (decreased splanchnic blood flow)
What is the treatment for acute variceal bleeding?
Octreotide + abx + endoscopic ligation/sclerotherapy
What is octreotide MOA?
Selective splanchnic vasoconstriction
What abx are used in acute variceal bleeding?
Cipro
Ceftriaxone
Why are abx used in acute variceal bleeds?
Reduces short term mortality
What are treatment options for refractory acute variceal bleeding?
Balloon tamponade
TIPS (transjugular intrahepatic portosystemic shunt)
What is the duration of octreotide in variceal bleeds?
2-5 days
What is the dosing of cipro for acute variceal bleeding?
400 mg IV or po q12h x 5-7 days or until discharge
What is the dosing of Ceftriaxone in acute variceal bleeding?
1g IV QD x 5-7 days if FQ resistance is suspected
What is the treatment of refractory acute variceal bleeding?
Balloon tamponade (temporary) TIPS
What is secondary prevention of bleeding that is required?
Treatment: propranolol titrated to HR 55-65
Endoscopic ligation
What is the cause of ascites in variceal bleeding?
Portal HTN and low albumin
What are the treatment goals of ascites?
Control ascites
Prevent SBP and hepatorenal syndrome
Prevent or relieve ascites-related symptoms
What is the dietary restriction for ascites?
Na restriction (<2,000mg/d) and diuretics
What diuretics are used in ascites?
Furosemide 40mg and Spironolactone 100mg in single am dose
Increase by doubling dose
What is the max furosemide dose in ascites?
160mg/d
What is the max spironolactone dose in ascites?
400mg/d
What do we monitor with lasix/spironolactone use?
Na
K
SCr
How do we treat refractory ascites?
Midodrine (7.5 mg po TID) + diuretic therapy
Paracentesis
Liver transplant
What classes of medications may be harmful to pts with ascites?
ACE/ARBs
NSAIDs (bleeding)
What is spontaneous bacterial peritonitis?
Infection of previously sterile ascetic fluid w/o apparent intra-abdominal source probably d/t seeding of the ascetic fluid from an episode of bacteremia
What are the common causes of SBP?
Enteric G- pathogens
Single bacterial species
What do we collect prior to initiating SBP empiric therapy?
Ascetic fluid
When do we give empiric abx for SBP?
PMNs >/= 250
When do we treat a patient empirically if their PMNs = 250?
Patient has s/sx of infection
What medications can be given for empiric therapy of SBP?
3rd gen ceph (cefotaxime/ceftriaxone) IV
Oral FQ
Which medications do we avoid in empiric therapy of SBP?
AG - high risk of renal failure in cirrhotic patients with SBP
What is the duration of therapy in SBP
5-10 days
What can we give to prevent hepatorenal syndrome?
Albumin
What is primary prophylaxis of SBP?
Norfloxacin/Bactrim for 7 days in patients with GI bleeding
What is secondary prophylaxis of SBP?
Norfloxacin/Bactrim dosed each day indefinitely (if ascites)
What causes hepatic encephalopathy?
Impaired brain function associated with hepatic insufficiency
Accumulation of nitrogenous substances (mainly NH3) from the gut
Activation of GABA by endogenous benzodiazepine-like substances
What are the ways to classify hepatic encephalopathy?
West Haven Criteria and Glasgow Coma Scale
