Cirrhosis Flashcards
What factors can precipitate hepatic encephalopathy in cirrhotic pts?
drugs (sedatives)
hypovolumia (diarrhea, vomiting, diuretic use, excessive paracentesis),
excessive nitrogen (GI bleeding, constipation, high protein diet)
hypokalemia and metabolic alkalosis hypoxia and hypoglycemia
infection (pneumonia, UTI, SBP)
portosystemic shunting (surgical and radiographical placed shunts)
Subtle signs of hepatic encephalopathy:
reversal of sleep wake cycle, progressing to confusion. Worse can progress to coma and death if untreated.
What are the lab values that patients can safely do paracentesis?
INR of 9 or PLT of 19.
1st line treatment of hepatic encephalopathy
lactulose (oral or rectal) and titrate to two to three bowel movements per day.
what is hepatopulmonary syndrome?
seen in cirrhosis who develop dypsnea on exertion or rest, platiypnea, orthodeoxia, chronic hypoxemia from portal hypertension and presents years after onset of chronic lifer disease
classic triad of hepatopulmonary syndrome:
liver disease, hypoxemia, and intrapulmonary vascular dilations (IPVDs)
IPVD or intrapulmonary vascular dilations cause what
right to left shunting which results in cyanosis and hypoxemia in hepatopulmonary syndrome
diagnosis of hepatopulmonary syndrome
liver disease, decreased oxygen and intrapulmonary vascular dilations
Diagnosis of hepatopulmonary syndrome
contrast echocardiogram (bubble study) showing right to left intracardiac or intrapulmonary shunt also clinical triad of liver disease and decreased oxygenation and IPVDs
Pulmonary symptoms on presentation and manifestations of hepatopulmonary syndrome
dypsnea on rest or exertion platypnea (increased dyspnea with sitting upright or relieved when supine) orthodeoxia (decreased areterial saturation by 5% from supine to upright, chronic hypoxemia with peripheral cyanosis
Hepatic manifestations of hepatopulmonary syndrome
stigmata of cirrhosis (spider nevi, splenomegaly, palmar erythema, ascites, clubbing, and hyperdynamic circulation and elevated cardiac output and decreased systemic and pulmonary vascular resistance)
what do you see on contrast echocardiography (bubble study) with HPS (hepatopulmonary syndrome)?
see left heart opacification 3-6 heart beats after right heart opacification which confirms intrapulmonary right o left shunt if microbubbles pass through dilated pulmonary vessels
Treatment of hepatopulmonary syndrome
no good treatment other than could consider liver transplant with severe hypoxemia.
New diagnosis of cirrhosis. what do you warn them to not do:
no eating rawshell fish (vibro vulnificus exposure) and no NSAIDS, no over the counter herbal supplements without talking to doctor 1st.
hx of cirrhosis varices and continued ETOH with new hematemesis and hypotension
variceal hemorrhage
management of variceal hemorrhage
HDS resuscitation, prevention and treatment of complications and stop bleeding
how to treat variceal hemorrhage
Need volume resuscitation, octreotide (constrict splanchnic circulation and reduce blood flow to portal vein) and needs urgent EGD. Also need abx to prevent SBP and UTI. Give prior to EGD and continue even if cultures are negative
SBP prophylaxis
norfloxacin, ciprofloxacin, or ceftriaxone for 7 days even if cultures are negative. Do this in any GI bleed and cirrhosis pt
SBP is defined by:
PMN >250 cell/mm3
SAAG or serum ascites albumin gradient is
>1.1 g/dl have ascites due to portal hypertension
greater gradient means liver is not making albumin like in cirrhosis
>2.5 total protein points to heart failure
<2.5 total protein points to cirrhosis
SAAG<1.1 and total protein <2.5 points to nephrotic syndrome
portal hypertension management:
managed initially with complete alcohol abstinence and 2 g/day sodium diet
Pts who don’t have improvement (remain symptomatic and have serum sodium >120) with ascites and portal hypertension despite stopping EOTH and sodium restriction should have:
combination oral high dose spironolactone and low dose lasix to reduce fluid retention and avoid hyperkalemia from spironolactone spironolactone 100 mg and lasix 40 mg ratio.
Can spironolactone be used as a single agent for treatment of ascites and portal HTN?
yes only if there’s profound hypokalemia.
why do we avoid use of IV lasix with ascites and portal HTN
risk for acute pre renal azotemia which can be confused with hepatorenal syndrome
what do we do for pts who have refractory ascites?
need large volume paracentesis midodrine transjugular intrahepatic portosystemic stent shunt (TIPS) liver transplant
what medications should be avoided in cirrhosis?
NSAIDs, ACEi and ARBs because they can reduce GFR and precipitate renal failure.
BP drops with increased nitric oxide release and worsened portal HTN and so the body naturally increases vasopressins (aldosterone and vasopressin and anigotensin) to keep BP up and renal perfusion up. These meds impair the body’s and can worsen renal blood flow and prevent excretion of salt and worsen ascites due to portal HTN.
what do most cirrhotics die from?
renal failure, infection, GI bleeds.