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GI/Hepatic Final > Cirrhosis > Flashcards

Cirrhosis Flashcards

1
Q

What is the gold standard for cirrhosis diagnosis?

A

Liver biopsy

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2
Q

Is cirrhosis a disease?

A

No, it is a final common pathway of liver damage

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3
Q

What does cirrhosis result from?

A

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

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4
Q

What do the grades rate in cirrhosis?

A

Degree of liver inflammation

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5
Q

What do the stages rate in cirrhosis?

A

Degree of fibrosis

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6
Q

What are the effects of portal HTN?

A 
Esophageal varices (hematemesis)
Melena (gastrophy)
Splenomegaly
Dilated abdominal veins (caput medusa)
Ascites (more advanced)
Rectal varices (hemorrhoids)
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7
Q

What are the effects of liver cell failures?

A 
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
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8
Q

What is compensated cirrhosis?

A

Further substaged by presence of mild mortal HTN or clinically significant portal HTN
Median survival: >12 years

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9
Q

What is decompensated cirrhosis?

A

Presence of ascites, variceal hemorrhage, and/or hepatic encephalopathy
Median survival: 2 years

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10
Q

What are the potential complications of cirrhosis?

A 
Portal HTN
VAriceal bleeding
Ascites
Spontaneous bacterial peritonitis
Hepatic encephalopathy
Hepatorenal syndrome
Coagulation disorders
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11
Q

What are coagulation disorders

A

Both pro- and anticoagulant proteins are reduced with a tendency toward hypocoagulability in earlier stages of cirrhosis
Bleeding
Portal vein thrombosis

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12
Q

What are general supportive care for cirrhosis?

A

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

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13
Q

What is portal HTN?

A

Increased resistance to blood flow in the liver ultimately resulting in the formation of collateral blood vessels (varices) in an attempt to reduce resistance

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14
Q

When do we prophylax for varices?

A

ALL patients with medium to large varices

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15
Q

What is primary prophylaxis for varices?

A

Non-selective Beta-blockers

Propranolol - is most common

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16
Q

What do we do if the pt cannot take beta-blockers for prophylaxis of varices?

A

Endoscopic varcieal ligation

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17
Q

What is the MOA of beta-blockers in variceal bleeds?

A

Decrease portal venous inflow through B1-adrenergic blockade (decreased CO) and B2-adrenergic blockade (decreased splanchnic blood flow)

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18
Q

What is the treatment for acute variceal bleeding?

A

Octreotide + abx + endoscopic ligation/sclerotherapy

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19
Q

What is octreotide MOA?

A

Selective splanchnic vasoconstriction

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20
Q

What abx are used in acute variceal bleeding?

A

Cipro

Ceftriaxone

21
Q

Why are abx used in acute variceal bleeds?

A

Reduces short term mortality

22
Q

What are treatment options for refractory acute variceal bleeding?

A

Balloon tamponade

TIPS (transjugular intrahepatic portosystemic shunt)

23
Q

What is the duration of octreotide in variceal bleeds?

A

2-5 days

24
Q

What is the dosing of cipro for acute variceal bleeding?

A

400 mg IV or po q12h x 5-7 days or until discharge

25
Q

What is the dosing of Ceftriaxone in acute variceal bleeding?

A

1g IV QD x 5-7 days if FQ resistance is suspected

26
Q

What is the treatment of refractory acute variceal bleeding?

A 
Balloon tamponade (temporary)
TIPS
27
Q

What is secondary prevention of bleeding that is required?

A

Treatment: propranolol titrated to HR 55-65

Endoscopic ligation

28
Q

What is the cause of ascites in variceal bleeding?

A

Portal HTN and low albumin

29
Q

What are the treatment goals of ascites?

A

Control ascites
Prevent SBP and hepatorenal syndrome
Prevent or relieve ascites-related symptoms

30
Q

What is the dietary restriction for ascites?

A

Na restriction (<2,000mg/d) and diuretics

31
Q

What diuretics are used in ascites?

A

Furosemide 40mg and Spironolactone 100mg in single am dose

Increase by doubling dose

32
Q

What is the max furosemide dose in ascites?

A

160mg/d

33
Q

What is the max spironolactone dose in ascites?

A

400mg/d

34
Q

What do we monitor with lasix/spironolactone use?

A

Na
K
SCr

35
Q

How do we treat refractory ascites?

A

Midodrine (7.5 mg po TID) + diuretic therapy
Paracentesis
Liver transplant

36
Q

What classes of medications may be harmful to pts with ascites?

A

ACE/ARBs

NSAIDs (bleeding)

37
Q

What is spontaneous bacterial peritonitis?

A

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

38
Q

What are the common causes of SBP?

A

Enteric G- pathogens

Single bacterial species

39
Q

What do we collect prior to initiating SBP empiric therapy?

A

Ascetic fluid

40
Q

When do we give empiric abx for SBP?

A

PMNs >/= 250

41
Q

When do we treat a patient empirically if their PMNs = 250?

A

Patient has s/sx of infection

42
Q

What medications can be given for empiric therapy of SBP?

A

3rd gen ceph (cefotaxime/ceftriaxone) IV

Oral FQ

43
Q

Which medications do we avoid in empiric therapy of SBP?

A

AG - high risk of renal failure in cirrhotic patients with SBP

44
Q

What is the duration of therapy in SBP

A

5-10 days

45
Q

What can we give to prevent hepatorenal syndrome?

A

Albumin

46
Q

What is primary prophylaxis of SBP?

A

Norfloxacin/Bactrim for 7 days in patients with GI bleeding

47
Q

What is secondary prophylaxis of SBP?

A

Norfloxacin/Bactrim dosed each day indefinitely (if ascites)

48
Q

What causes hepatic encephalopathy?

A

Impaired brain function associated with hepatic insufficiency
Accumulation of nitrogenous substances (mainly NH3) from the gut
Activation of GABA by endogenous benzodiazepine-like substances

49
Q

What are the ways to classify hepatic encephalopathy?

A

West Haven Criteria and Glasgow Coma Scale

GI/Hepatic Final (6 decks)

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