Cirrhosis Flashcards
Who can Pruritis develop in?
Can develop in patients who have cholestasis due to any cause. Ie: intrahepatic cholestasis of pregnancy, primary sclerosing cholangitis, malignant biliary tract obstruction, chronic viral hepatitis, nonmalignant biliary tract obstruction, cirrhosis.
What is the pathology behind Pruritis?
Incompletely understood. Probably has to due with elevated levels of bile acids in the skin that can act as pruritogens.
Endogenous opioid theory - levels are elevated in patients with chronic liver disease
Lysophosphatidic acid and autotaxin - phosphospholipid formed by action of autotaxin. Patients have much higher serum LPA and autotaxin, injection of LPA induced scratch response in mice.
What are the treatments for Cholestatic Pruritis?
Bile acid sequestrant is first line ie: cholestyramine (questran) or colestipol (colestid) - 80-85% of patients respond.
2nd line - Rifampin (Rifampicin)
3rd line - Opioid antagonist - Naltrexone (Vivitrol) If all else fails - sertraline or phenobarbital.
Whats a MELD score? What criteria does it use? What does a higher score indicate?
Model for End-Stage Liver Disease
Uses Serum bilirubin, creatinine, INR, and whether a patient has recently had dialysis to predict a 3 month survival
Higher score = worse liver dysfunction and increased mortality risk. Used to prioritize patients awating liver transplant.
How do you screen and treat Variceal hemorrhages?
EGD screening
Band ligation for treatment if found on EGD
Otherwise - non selective beta blocker ie (propranolol)
How do you manage Ascites?
Diuretics - Spironolactone/furosemide 100:40 mg/day
Paracentesis
Sodium restriction and alcohol abstinence
How do you diagnose and how do you manage spontaneous bacterial peritonitis?
Diagnosed with ascetic fluid bacterial culture and or increased polymorphonuclear leukocyte count >250cells/mm^3 on eval of ascetic fluid
Empiric antibiotics - cefotaxime 2g IV Q8H
Prophylactic antibotics for those who survive an episode - norfloxacin or Bactim
What is hepatorenal syndrome?
Development of renal failure in a patient with advanced liver disease
Renal perfusion decreased by hepatic dysfunction (reduced effective blood volume)
Diagnosis of exclusion.
How do you manage hepatic hydrothorax?
This is the presence of effusion in patient with cirrhosis and no evidence of underlying cardiopulmonary disease.
tx: diuretics, sodium restriction, thoracentesis if needed.
How do you manage hepatopulmonary syndrome?
Progressive abnormal arterial oxygenation caused by intrapulmonary vascular dilatations (IPVDs) in the setting of liver disease
No medical therapy other than long term o2, liver transplant is definitive tx.
How do you manage Hepatic encephalopathy?
Address any precipitating factors
Lactulose - leads to decreased ammonia in the GI tract - titrate until patient is having 2-3 loose stools/day.
Nonabsorbable antibiotics - rifaximin - generally added to lactulose therapy or used in those who can’t tolerate lactulose
Often you used lactulose and rifaximin together - mortality benefit.
How do you manage HCC?
Diagnosed by serial ultrasound every 6 months.
Surgical resection is the preferred therapy
only other option is liver transplant.
What screening do you need to do for patients first diagnosed with cirrhosis?
EGD for esophageal varices
Serial ultrasounds for HCC
Neuro exam and testing for Hepatic encephalopathy.
What follow ups should you make for the patient?
GI: Hepatology - Cirrhosis and Hep C
Nephrology
Psychology/psychiatry
Smoking cessation
Alcohol rehab, AA
A patient with anti-HBc tells you?
They have either had hepatitis B in the past or have it concurrently - doesn’t tell you if theyre immune or not.
