Cirrhosis Flashcards
What are two major factors that can cause cirrhosis?
Hepatitis and alcohol
True or False? A patient with cirrhosis may be asymptomatic
True
What clinical presentation can be seen in a patient with cirrhosis?
Abdominal discomfort, weakness, malaise, ascites, jaundice
What lab values may be abnormal in a patient with cirrhosis?
Prolonged prothrombin time (increased INR), decreased albumin, thrombocytopenia
What are the ranges of scores for a “Child-Pugh Score” and what do they represent?
5-6: Class A (well-compensated) - 100% survival
7-9: Class B (significant compromise) - 80% survival
10-15: Class C (decompensated) - 45% survival
True or False? Cirrhosis can cause portal hypertension
True. This can cause structural changes and vascular tone changes
How do you calculate a hepatic venous pressure gradient (HVPG)?
HVPG = Wedged Hepatic Venous Pressure (WHVP) - Free Hepatic Venous Pressure (FHVP)
What is a normal HVPG and what score determines if someone has portal hypertension? What score puts you at risk of hemorrhage?
Normal: < 5mmHg
Portal hypertension: >= 6mmHg
Risk of hemorrhage: > 12mmHg
True or False? Varices put you at a lower risk of bleeding
False. They put you at a higher risk
What % of cirrhotic patients have varices?
50%
Patients with varices have a goal HVPG of < ___mmHg or ___% of baseline and ___ heart rate
<12mmHg
20%
Decreased
What are first line agents for lowering heart rate in patients with cirrhosis?
Non-selective beta blockers: Nadolol 20-40mg QD Propranolol 20-40mg BID Carvedilol 6.25mg QD These will reduce the heart rate and variceal bleeding by 50%
What is a serious adverse effect of beta blockers in reducing variceal bleeding?
Spontaneous bacterial peritonitis
The goal of variceal hemorrhage therapy is to prevent ___ week mortality
6
What is an example of non-pharmacologic therapy to reduce varices?
Endoscopic variceal ligation (EVL) every 2 to 8 weeks until varices are gone. This is an elastic band around the varix
What are first line pharmacologic therapies for variceal hemorrhage?
Ocreotide (1st line), vasopressin
What antibiotics are given as prophylaxis to treat variceal hemorrhages?
Ceftriaxone 1g IVPB Q24hr for 7 days
Cipro 400mg IVPB Q12hr for 7 days
What medications are given as secondary prophylaxis to variceal hemorrhage?
Non-selective beta blockers: Nadolol 20-40mg QD Propranolol 20-40mg BID Carvedilol 6.25mg QD These are used in both variceal bleeding and variceal hemorrhage
What is the clinical presentation of ascites?
Weight gain, increased abdomen size, shortness of breath
Ascites is present in cases of cirrhosis due to retention of ___ and ___
Na
Water
How do you calculate a serum ascites albumin gradient (SAAG)?
SAAG = serum albumin – ascites albumin
If SAAG is > ___mg/dL, the patient has portal hypertension
1.1mg/dL
___ replenishment is necessary for a patient with ascites
Albumin
How is ascites treated?
Na restriction (<2g daily)
Fluid restriction
Ratio of 40 mg furosemide: 100 mg spironolactone
(if low weight, 20mg furosemide: 50mg spironolactone)
___ to ___% of people with spontaneous bacterial peritonitis are asymptomatic
10-20%
What are symptoms of spontaneous bacterial peritonitis?
Fever, abdominal pain, change in mental status
In order to diagnose spontaneous bacterial peritonitis, a patient’s polymorphonuclear cell count (PMN) must be > ___
250
What antibiotics are given to treat spontaneous bacterial peritonitis?
Ceftriaxone 2g IVPB Q24hr
Cefotaxime 2g IVPB 18hr
___ must be replenished in patients with spontaneous bacterial peritonitis in order to prevent renal failure
Albumin
What antibiotics are given as prophylaxis for patients with spontaneous bacterial peritonitis?
Cipro or bactrim
A complication of cirrhosis is hepatic encephalopathy (liver damage). What are symptoms of this?
Memory loss, decreased concentration, decreased sleep, increased lethargy
What is used for treatment of hepatic encephalopathy?
Lactulose (1st line). If not working, add rifaximin
A complication of cirrhosis is hepatorenal syndrome. What are the differences between type 1 and type 2 hepatorenal syndrome?
Type 1 - rapid and progressive decrease in renal function
Type 2 - Gradual and slow decrease in renal function
How do you treat hepatorenal syndrome?
A combinaton of midodrine, ocreotide, albumin
