Cirrhosis Flashcards by Kelsey Con

top two causes

chronic alcohol abuse

chronic hep C

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5 complications

portal hypertension
esophageal and gastric varices with risk of variceal bleeding
ascites
spontaneous bacterial peritonitis 
hepatic encephalopathy

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what is portal hypertension

increased BP in the portal venous system

hepatic venous pressure gradient >5mmHG

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how does portal hypertension develop

scarring of liver causes mechanical obstruction of blood flow from portal vein to liver
splanchnic arterial vasodilation and decreased response to vasoconstrictors increases blood flow to portal vein

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what causes varices

portal hypertension with HVPG>10mmHg

small veins in lower esophagus and stomach become distended as blood is redirected

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what is ascites

accumulation of fluid in the peritoneal cavity

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what causes ascites

increased nitric oxide causes vasodilation
decreased arterial blood volume activates RAAS = sodium retention therefore fluid pushes out on the wall
low serum albumin to push back on the wall and keep it in
fluid leaks into peritoneal cavity

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definition of spontaneous bacterial peritonitis

infection of ascitic fluid without an obvious surgically treatable source

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how does spontaneous bacterial peritonitis occur

bacteria from GI tract end up in ascitic fluid

exact mechanism not know

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common bacteria in SBP

ecoli
kpneumoniae
pneumococci

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how does hepatic encephalopathy occur

decreased liver function and shunting of blood around the liver causes neurotoxins to accumulate, affects brain function
most commonly ammonia

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diagnosing cirrhosis

signs and symptoms
lab values, endoscopy, radiographic tests
biopsy not necessary

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symptoms of cirrhosis

weight loss
fatigue
anorexia
jaundice
impotence
abdominal distention
confusion 
pruitis
GI bleed
dark colored urine

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physical signs of cirrhosis

hepatomegaly
splenomegaly 
spider angiomata
caput medusa
digital clubbing
gynecomastia
jaundice
asterix - hand flap 
ascites 
fector hepaticus - sweet smelling breath

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lab indicating alcoholic liver disease

AST:ALT 2:1

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labs that can be abnormal in cirrhosis

elevated aminotransferase
elevated alkaline phosphatase with GGT rise 
decreased serum albumin 
elevated INR
hyperbilitubinemia
increased serum creatinine
hyponatremia 
thrombocytopenia, leukopenia

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abnormal radiographic tests

ultrasonography - detects hepatic nodules, ascites

CT, MRI - detect hepatic nodules, ascites, varices

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child pugh classification used for

recommending drug dosage adjustments

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model for end stage liver disease score used for

allocation of liver transplants

predicts 3 month mortality

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grade A child pugh

<7points

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grade B child pugh

7-9 points

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grade C child pugh

> 9 points

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treat patients with no varices or small varices with no risk factors ?

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what are risk factors for variceal hemorrhage

red wales

child pugh score C

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treat small varices with risk factors for variceal hemorrhage?

yes with non selective beta blocker

treat medium to large varices with no bleeding?

yes with non selective beta blocker

what to treat varices with if have asthma or diabetes (beta blocker intolerant)

endoscopic variceal ligation - banding

non selective beta blocker options

propranolol 20mg BID nadolol 20mg daily carvediol 6.25 BID

monitoring of non selective beta blockers

titrate every 3 days to HR 55-6o bbp

when do you stop beta blocker therapy for varices

when in end stage liver disease

beta blocker MOA

decrease portal venous inflow by decreasing cardiac output - beta1 decreasing splanchnic blood flow - beta2

treatment of acute variceal bleeding

maintain BP with fluids, control bleeding octreotide asap endoscopic variceal ligation prophylaxis for SBP

what to do if still bleeding after octreotide and EVL

transjugular intrahepatic portosystemic shunt

octreotide dosing

50mcg IV then 50mcg/hr IV continuous x 3-5days

octreotide mechanism

inhibits vasodilatory glucagon and has local splanchnic vasoconstrictive effect

prophylaxis treatment for SBP durign acute variceal bleeding

cipro or ceftriaxone for 7 days

what is a transjugular intrahepatic portosystemic shunt

shunt that bypasses the liver

secondary prophylaxis of varices to prevent rebleed

non selective beta blocker + chronic EVL | if had TIPS possible liver transplant candidate

things to do for diagnosing of ascites

measure cell count, ascitic fluid total protein, ascitic fluid cultures calculate serum asciteis albumin gradient (serum albumin - ascitic fluid albumin)

diagnosis of ascites

SAAG >11g/L

treatment of ascites

furosemide 40 + spironolactone 100

non pharm for ascites

restrict salt <2g/day fluid too if hyponatremia avoid nsaids, acei

monitoring of ascites treament

titrate diuretics up every 3-5 days for 0.5kg weight loss daily monitor potassium and serum creatinine

treatment for ascites resistent to diuretics

therapeutic paracentesis

presentation of SBP

fever, ab pain, encephalopathy, confusion, renal failure

diagnoses of SBP

PMN >250cells/mm3 and positive ascitic fluid bacterial cultures

when to treat SBP

treat empirically (before culture back) if PMN >250 or signs/sx of infection

treatment of SBP

3rd generation cephalosporins perferred | quinolone second line

why cefotaxime is preferred over ceftriaxone

less bound to proteins in the blood and more easily passed into acidic fluid

cefotaxime treatment SBP dosing

2g IV q8h | 5 day treatment course

long term prophylaxis after SBP episode

septra lower dosing than standard treatment | ex septra DS 5x a week

precipitating factors for hepatic encephalopathy

electrolyte abnormalities - dehydration, diuretic overuse infection GI bleeding constipation

mainstay of hepatic encephalopathy treatment

reduce ammonia levels

first line for hepatic encephalopathy

lactulose - non absorbable disaccharide

how often to give lactulose and preferred route

q1hr | oral

mechanism of lactulose lowering ammonia

laxative effect - less time for systemic ammonia absorption from gut decreased pH so charged NH4+ cations trapped in acidic colon

titration for lactulose

3 soft stools daily

monitoring for lactulose

3 soft stools dialy | improved mental status

rifaximin MOA

porrly absorbed antibiotic | reduces ammonia producing bacteria in the gut

when to use rifaximin

with lactulose in recurrent HR not responding to max tolerated lactulose

why arent neomycin and metro use anymore

higher risk of side effects