Cirrhosis

Question 1

What are two major factors that can cause cirrhosis?

Answer 1

Hepatitis and alcohol

Question 2

True or False? A patient with cirrhosis may be asymptomatic

Answer 2

True

Question 3

What clinical presentation can be seen in a patient with cirrhosis?

Answer 3

Abdominal discomfort, weakness, malaise, ascites, jaundice

Question 4

What lab values may be abnormal in a patient with cirrhosis?

Answer 4

Prolonged prothrombin time (increased INR), decreased albumin, thrombocytopenia

Question 5

What are the ranges of scores for a “Child-Pugh Score” and what do they represent?

Answer 5

5-6: Class A (well-compensated) - 100% survival
7-9: Class B (significant compromise) - 80% survival
10-15: Class C (decompensated) - 45% survival

Question 6

True or False? Cirrhosis can cause portal hypertension

Answer 6

True. This can cause structural changes and vascular tone changes

Question 7

How do you calculate a hepatic venous pressure gradient (HVPG)?

Answer 7

HVPG = Wedged Hepatic Venous Pressure (WHVP) - Free Hepatic Venous Pressure (FHVP)

Question 8

What is a normal HVPG and what score determines if someone has portal hypertension? What score puts you at risk of hemorrhage?

Answer 8

Normal: < 5mmHg
Portal hypertension: >= 6mmHg
Risk of hemorrhage: > 12mmHg

Question 9

True or False? Varices put you at a lower risk of bleeding

Answer 9

False. They put you at a higher risk

Question 10

What % of cirrhotic patients have varices?

Answer 10

50%

Question 11

Patients with varices have a goal HVPG of < ___mmHg or ___% of baseline and ___ heart rate

Answer 11

<12mmHg
20%
Decreased

Question 12

What are first line agents for lowering heart rate in patients with cirrhosis?

Answer 12

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%

Question 13

What is a serious adverse effect of beta blockers in reducing variceal bleeding?

Answer 13

Spontaneous bacterial peritonitis

Question 14

The goal of variceal hemorrhage therapy is to prevent ___ week mortality

Answer 14

6

Question 15

What is an example of non-pharmacologic therapy to reduce varices?

Answer 15

Endoscopic variceal ligation (EVL) every 2 to 8 weeks until varices are gone. This is an elastic band around the varix

Question 16

What are first line pharmacologic therapies for variceal hemorrhage?

Answer 16

Ocreotide (1st line), vasopressin

Question 17

What antibiotics are given as prophylaxis to treat variceal hemorrhages?

Answer 17

Ceftriaxone 1g IVPB Q24hr for 7 days

Cipro 400mg IVPB Q12hr for 7 days

Question 18

What medications are given as secondary prophylaxis to variceal hemorrhage?

Answer 18

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

Question 19

What is the clinical presentation of ascites?

Answer 19

Weight gain, increased abdomen size, shortness of breath

Question 20

Ascites is present in cases of cirrhosis due to retention of ___ and ___

Answer 20

Na

Water

Question 21

How do you calculate a serum ascites albumin gradient (SAAG)?

Answer 21

SAAG = serum albumin – ascites albumin

Question 22

If SAAG is > ___mg/dL, the patient has portal hypertension

Answer 22

1.1mg/dL

Question 23

___ replenishment is necessary for a patient with ascites

Answer 23

Albumin

Question 24

How is ascites treated?

Answer 24

Na restriction (<2g daily)
Fluid restriction
Ratio of 40 mg furosemide: 100 mg spironolactone
(if low weight, 20mg furosemide: 50mg spironolactone)

Question 25

___ to ___% of people with spontaneous bacterial peritonitis are asymptomatic

Answer 25

10-20%

Question 26

What are symptoms of spontaneous bacterial peritonitis?

Answer 26

Fever, abdominal pain, change in mental status

Question 27

In order to diagnose spontaneous bacterial peritonitis, a patient's polymorphonuclear cell count (PMN) must be > ___

Answer 27

250

Question 28

What antibiotics are given to treat spontaneous bacterial peritonitis?

Answer 28

Ceftriaxone 2g IVPB Q24hr | Cefotaxime 2g IVPB 18hr

Question 29

___ must be replenished in patients with spontaneous bacterial peritonitis in order to prevent renal failure

Answer 29

Albumin

Question 30

What antibiotics are given as prophylaxis for patients with spontaneous bacterial peritonitis?

Answer 30

Cipro or bactrim

Question 31

A complication of cirrhosis is hepatic encephalopathy (liver damage). What are symptoms of this?

Answer 31

Memory loss, decreased concentration, decreased sleep, increased lethargy

Question 32

What is used for treatment of hepatic encephalopathy?

Answer 32

Lactulose (1st line). If not working, add rifaximin

Question 33

A complication of cirrhosis is hepatorenal syndrome. What are the differences between type 1 and type 2 hepatorenal syndrome?

Answer 33

Type 1 - rapid and progressive decrease in renal function | Type 2 - Gradual and slow decrease in renal function

Question 34

How do you treat hepatorenal syndrome?

Answer 34

A combinaton of midodrine, ocreotide, albumin