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Clinical Therapeutics 2 > Cirrhosis and its Complications > Flashcards

Cirrhosis and its Complications Flashcards

1
Q

what is the most common complication of cirrhosis?

A

ascites

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2
Q

most common cause of ascites?

A

cirrhosis

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3
Q

most common physical exam findings for ascites?

A

flank dullness and shifting dullness

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4
Q

what is the first physical exam finding for ascites?

A

flank dullness

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5
Q

if pt has ascites and chronic liver disease what are clues that tell you this?

A

Chronic liver disease

  • palmar erythema (very red palms)
  • spider nevi
  • jaundice (I.e. sclera icterus)
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6
Q

NEW cause of ascites requires what labs?

A
  • CBC, CMP, LFTs, Urea
  • Abdominal US
  • Dx Paracentesis
  • ascitic fluid analysis
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7
Q

what should you calculate for any cause of ascites?

A

SAAG (serum albumin acidic gradient)

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8
Q

what imaging should be done for ascites?

A

abdominal US

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9
Q

how do you get the fluid out to analyze it in ascites?

A

a paracentesis

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10
Q

routine tests for ascitic fluid?

A

total protein, albumin, cell count

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11
Q

a protein <2.5g/dL in the ascitic fluid is associated with what?

A

portal HTN and hypoalbuminemia

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12
Q

a protein >2.5g/dL in the ascitic fluid is associated with what?

A

TB, malignancy, pancreatitis, myxedema

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13
Q

what is SAAG?

A

serum albumin acidic gradient

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14
Q

how do you calculate SAAG?

A

SAAG = serum albumin - ascites albumin

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15
Q

what is a high SAAG? what does it indicate?

A

SAAG >1.1 g/dL

-indicates portal HTN and suggests a non-peritoneal cause of ascites

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16
Q

non-peritoneal causes of ascites?

A

may have clot in portal vein (want to keep pressure <10mmHg)

cirrhosis

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17
Q

how many grades of ascites?

A

3 grades

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18
Q

what is Grade I of ascites and its treatment?

A

Grade I = only detectable by USS

Tx: salt restriction

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19
Q

what is Grade II of ascites and its treatment?

A

Grade II = moderate symmetrical enlargement of abdomen - shifting dullness

Tx: salt restriction + diuretics

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20
Q

what Grade of ascites do you see a shifting dullness?

A

Grade II

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21
Q

what is Grade III of ascites and treatment?

A

Grade III - marked abdominal enlargement (hard as a rock) - transmitted thrill

Tx: large volume paracentesis + salt restriction + diuretics

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22
Q

what Grade of ascites do you see a transmitted thrill?

A

Grade III

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23
Q

how can Grade II ascites pts be treated?

A

as outpatients unless there are other complications of cirrhosis

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24
Q

is renal sodium impaired in Grade II ascites?

A

renal sodium is not severely impaired, but excretion is low compared to intake

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25
Q

aim for what when treating Grade II ascites?

A

aim for negative sodium balance

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26
Q

when is fluid restriction required for tx of Grade II ascites?

A

only in those with dilution hyponatremia (Na <125)

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27
Q

normal sodium level?

A

135-145

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28
Q

in pts with cirrhosis, renal sodium is due to what?

A

renal sodium retention is d/t increased proximal and distal tubular sodium reabsorption rather than a decrease of filtered sodium

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29
Q

medications for Grade II ascites tx?

A

Diuretics - aldosterone antagonists (Spironolactone)

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30
Q

after 1st episode of Grade II ascites, what med do you start the pt on?

A

Spironolactone 100mg/day and increase 100mg/day stepwise every 7 days to max dose of 400mg/day

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31
Q

when would you add Furosemide to a Grade II ascites pts tx?

A

if no response to spironolactone (reduction of body weight < 2kg/week) or if develop hyperkalemia (from the spironolactone)

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32
Q

why is Spironolactone first choice med tx for ascites?

A

b/c activates RAAS to get rid of the fluid (inhibits aldosterone)

ascites pts have increased serum aldosterone d/t activation of RAAS

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33
Q

what is the max recommended weight loss for pt with Grade II ascites?

A

Max recommended weight loss should be 0.5kg/day in patients without edema or 1kg/day if have edema

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34
Q

when are diuretics are C/I in ascites?

A

if overt hepatic encephalopathy

-diuretics cause hypovolemia and hypovolemia worsens the hepatic encephalopathy (more build up on ammonia)

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35
Q

when do you D/C diuretics for ascites?

A

if severe hyponatremia (Na <120), renal failure, worsening encephalopathy or incapacitating muscle cramps

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36
Q

when should Furosemide be stopped for tx of ascites?

A

if hypokalemia (K < 3)

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37
Q

Grade III ascites management

A

Large Volume Paracentesis (LVP) + Albumin

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38
Q

LVP + Albumin is safer than diuretics terms of what?

A

in terms of hyponatremia, renal impairment, encephalopathy

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39
Q

LVP reduces what? but can cause what?

A

Reduces effective blood volume HOWEVER this can cause post-paracentesis circulatory dysfunction

40
Q

the post-paracentesis circulatory dysfunction that can occur with LVP can lead to what?

A

rapid re-accumulation of ascites

41
Q

what can increase in pts with circulatory dysfunction after LVP?

A

portal pressure

42
Q

to prevent post-paracentesis circulatory dysfunction with LVP, what do you infuse?

A

infuse ALBUMIN 6-8g/Liter of fluid removed

43
Q

resume what meds post LVP?

A

resume diuretics post LVP (if pt is doing ok)

44
Q

do cirrhotic pts have a lot of hemorrhagic complications with LVP?

A

NO!!!

45
Q

if pt has an abdominal scar (I.e. from hernia repair), where do you do the paracentesis?

A

DO NOT DO PARACENTESIS ON SAME SIDE AS ABD SCAR B/C ADHESIONS CAN ADHERE TO ABDOMINAL WALL

DO PARACENTESIS ON OPPOSITE SIDE!!!

46
Q

when is TIPS indicated for ascites?

A

if paracentesis is not effective

47
Q

who is TIPS for?

A

For pts with refractory ascites needing frequent paracentesis (>3/month) who are not candidates for liver transplantation

48
Q

what does TIPS do?

A

decreases vascular resistance of the liver by creating a shunt b/w the higher-pressure portal vein and the lower-pressure hepatic vein -> DECREASING PORTAL VENOUS PRESSURE

THUS REDUCES PRODUCTION OF ASCITES

49
Q

bad side effect of TIPS?

A

hepatic encephalopathy

50
Q

Complications of ascites

A

Umbilical hernia (d/t pressure behind belly button)

Hydrothorax
-Pleural effusion, Right > Left

51
Q

what sided pleural effusion is a common complication of ascites?

A

right sided pleural effusion

52
Q

all pts with ascites are at risk for what?

A

SBP (spontaneous bacterial peritonitis)

53
Q

what is SBP?

A

infection of the peritoneal fluid

54
Q

Clinical presentation of SBP

A

abd pain, tenderness, emesis, fever (pt appears sick)

elevated WBC

pt may be asymptomatic

55
Q

at what ascitic neutrophil count do you assume pt has SBP?

A

Ascitic neutrophils count >250/mm3

56
Q

what is culture-negative SBP?

A

fluid cell count >250 but culture negative

57
Q

what is Bacterascites for SBP?

A

fluid cell count <250 but positive cultures

-possibly early SBP

58
Q

if ascitic fluid cx is negative what do you do?

A

repeat and if cell count remains >250 then treat (with abx - Ceftriaxone)

59
Q

if ascitic fluid cx is <250, what do you do?

A

draw again to confirm ascetic neutrophils count is low (but better to treat than not treat)

60
Q

most common pathogens for SBP?

A

gram negatives -> e.coli

gram positives -> streptococcus

61
Q

Tx of choice for SBP?

A

Ceftriaxone IV

62
Q

2nd line abx for tx of SBP?

A

amoxicillin/clavulanic acid and fluoroquinolones

63
Q

when do you avoid fluroquinolones for tx of SBP?

A

if the pt is on them for SBP ppx

64
Q

what do you repeat after treatment of SBP?

A

repeat paracentesis to ensure ascetic neutrophil count <250/mm3 and sterile cultures after treatment

65
Q

if SBP pt is worsening after 48hrs of abx tx, what may it be?

A

may be due to abx resistance or secondary bacterial peritonitis

66
Q

what is hepatorenal syndrome?

A

occurrence of renal failure in patient with advanced liver disease in absence of identifiable cause of renal failure

67
Q

what do you need to r/o before dx hepatorenal syndrome (HRS)?

A
  • Hypovolemia
  • Shock
  • Parenchymal renal disease
  • Nephrotoxins (ex: morphine, Lasix -> these ruin the kidney)
68
Q

consider parenchymal renal disease (CKD) when?

A

if significant proteinuria or micro-hematuria, renal U/S abnormalities

69
Q

criteria for dx of HRS in cirrhosis?

A

Cirrhosis with ascites
-serum Cr >1.5mg/dl (133 mol/L)

Absence of shock

No current or recent tx with nephrotoxic drugs

70
Q

Absence of shock criteria for dx of HRS in cirrhosis is what?

A

absence of hypovolemia by no sustained improvement of renal function (Cr <133) following at least 2 days of diuretic withdrawal, and volume expansion with albumin

71
Q

No current or recent tx w/nephrotoxic drugs for dx of HRS in cirrhosis is what?

A

absence of parenchymal renal disease as defined by proteinuria <0.5 g/day, no microhaematuria (<50 red cells/high powered filed), and normal renal ultrasonography

72
Q

cirrhosis with ascites for dx of HRS in cirrhosis is what?

A

serum Cr >1.5mg/dl (133 mol/L)

73
Q

what are the 2 types of HRS?

A

HRS1
-rapid progressive impairment in renal function (over 100% increase in creatinine in less than 2 weeks) í happens faster than HRS2

HRS2
-stable and less progressive impairment in renal function

74
Q

what has the highest risk of developing HRS? means what?

A

development of infections (SBP) -> means need to dx and treat to improve survival

75
Q

where should pts with HRS be monitored?

A

in the ICU

76
Q

monitor what in HRS?

A

urine output, fluid balance, ideally CVP (in the ICU)

77
Q

what do you screen for in HRS management?

A

sepsis screening

-blood and ascetic culture, ppx abx if no active infection

78
Q

what meds to use for HRS management?

A

Vasopressin analogues

-improves renal fxn in Type 1 HRS

79
Q

what replacement therapy should be done for HRS management?

A

renal replacement therapy (hemodialysis)

-hyperkalemia, volume, metabolic acidosis

80
Q

___ transplant should be done ASAP for HRS

A

Liver transplant

81
Q

what meds should be stopped if pt has HRS?

A

Diuretics

82
Q

what is hepatic encephalopathy characterized as?

A

personality changes, intellectual impairment, and a depressed level of consciousness

83
Q

why does ammonia build up in liver failure?

A

b/c have less hepatocytes able to detoxify the ammonia

84
Q

hepatic encephalopathy precipitating factors

A

Constipation - not pooping out ammonia

Infections - bacteria may increase ammonia load

GI Bleeding - increase in nitrogenous load in the GIT and therefore increased ammonia level

Shunts - increases HE (ex: TIPS procedure)

Renal Failure - decreased clearance of urea, ammonia, and other nitrogenous compounds

Medications - benzo’s, antidepressants, antipsychotics (all act on CNS)

Diuretics - decrease K levels and alkalosis making it more difficult to convert ammonia to ammonium -> build up of ammonia

85
Q

what is the first thing to do when managing hepatic encephalopathy?

A

that there are no other causes for the encephalopathy

  • obtain head CT, r/o bleeds or lesions
  • EEG to r/o seizure activity
86
Q

what level should you get for hepatic encephalopathy?

A

ammonia level - get once, don’t need to follow it

87
Q

1 medication for treatment of hepatic encephalopathy?

A

Lactulose - has laxative effect to remove nitrogenous wastes and bacteria

88
Q

Lactulose dose to start

A

20-60ml 3x/day, titrated to achieve 2-4 soft stools/day without diarrhea

89
Q

what must you warn pt on Lactulose?

A

Warn the patient to not overdose as can cause hypovolemia, thus worsening the encephalopathy

-when hypovolemic, also more acidotic, thus body makes more ammonia

90
Q

how can Lactulose be administered?

A

NGT or enema in hospitalized pts unable to take themselves

91
Q

what are the 2nd line agents to treat hepatic encephalopathy?

A

Abx - Neomycin, Flagyl, PO Vanco, Rifaximin

-used after failure of Lactulose

92
Q

when are abx used to treat hepatic encephalopathy?

A

after failure of Lactulose

93
Q

what else can be used for tx of hepatic encephalopathy besides Lactulose and Abx?

A

Probiotics - make colon empty quicker (have a laxative effect)

Fermentable fibers - help modulate acidity of gut so the bacteria that make ammonia can’t go to the liver

94
Q

if pt has ascites and Portal HTN what are clues that tell you this?

A

Portal HTN

-splenomegaly and large collateral veins (caput medusa)

95
Q

if pt has ascites and cardiac problems/lymph nodes problems, what are some clues?

A

Cardiac
-engorged jugular veins

Lymph Nodes
-TB or Lymphoma

Clinical Therapeutics 2 (11 decks)

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