Cirrhosis and Liver Disease Part II (exam 3) Flashcards
screening tests for varices
transient elastography
EGD
when liver stiffness is ______________ and platelets are ______________ there is a low risk of varices
under 20 pKa
over 150,000
when liver stiffness is ______________ and platelets are ______________, _________ is recommended
over 20 kPa
EGD
EGD
invasive
varices can be seen
required for patients with high risk TE
repeat annually for patients who have low risk findings
indications for primary prophylaxis of variceal bleeding if the patient has compensated cirrhosis
clinically significant portal hypertension
the goal of primary prophylaxis of variceal bleeding if the patient has compensated cirrhosis is
prevention of cirrhosis decompensation
indications for primary prophylaxis of variceal bleeding if the patient has decompensated cirrhosis
medium/large varices NEED
small varices - Child-Pugh class C, Red Wale Marks (at least one)
preferred therapy for primary prophylaxis of variceal bleeding
nonselective beta blocker (carvedilol, propanolol, nadolol)
__________ is preferred for variceal bleeding in compensated cirrhosis
carvedilol
what agent is recommended for primary prophylaxis for variceal bleeding in decompensated cirrhosis?
any nonselective beta blocker
alternative method of prophylaxis available for medium/large varices only
endoscopic variceal ligation (EVL)
endoscopic variceal ligation
placement of rubber bands around varices
q1-2 weeks until obliteration of varices
consider _______ when beta blockers cannot be used
EVL
when can EVL not be done?
in patients with small varices
nonselective beta blockers decrease portal pressure by
reducing portal venous flow
beta blockers contraindications
asthma
extreme bradycardia
2nd, 3rd degree AV block w/o implanted pacemaker
insulin dependent DM with hypoglycemic episodes
PAD
beta blockers adverse effects
hypotension
bradycardia
CNS effects
worsening of lung disease
use beta blockers with caution in ________________ because it may worsen outcomes
refractory ascites
treat acute variceal bleeding as
a medical emergency (ICU)
in a patient with acute variceal bleeding, provide ___________________ to maintain hemodynamic stability
intravascular support and blood transfusions
pharmacotherapy for acute variceal bleeding
octreotide (most common)
terlipressin
somatostatin
vasopressin
start pharmacotherapy for acute variceal bleeding as soon as
variceal bleeding is suspected
endoscopic therapy for acute variceal bleeding
perform EGD within 12 hours
EVL (preferred)
1st line therapy for acute variceal bleeding
octreotide (Sandostatin)
MOA of octreotide
local splanchnic vasoconstriction and decreased portal inflow
less systemic side effects than vasopressin
while on octreotide, monitor
hyperglycemia
bradycardia
HTN
arrhythmia
abdominal pain
vomiting
start all patients with variceal bleeding on a short course of
antibiotics
preferred antibiotic for variceal bleeding
ceftriaxone (1g/day) x 7 days
balloon tamponade
temporarily effective in stopping bleeds
rebleeding is common
TIPS (transjugular intrahepatic portosystemic shunt)
stents placed between the hepatic and portal veins
decreased incidence of rebleeding
TIPS is indicated in those
with high risk hemorrhage
who fail to achieve hemostasis standard treatment
who requires secondary prophylaxis for variceal bleeding?
what is recommended?
all patients!
combination of EVL and nonselective BB
exceptions for secondary prophylaxis for variceal bleeding
patients who received TIPs procedure
when assessing a patient with ascites, perform a
abdominal paracentesis
what is an abdominal paracentesis
needle is inserted into peritoneal cavity and ascitic fluid is removed
after abdominal paracentesis is performed __________ is analyzed for
ascitic fluid
cell count with differential, total protein and culture of fluid
serum-ascites albumin gradient (SAAG)
serum albumin - ascitic fluid albumin
if SAAG is greater or equal to 1.1 g/dl
there is portal HTN
if SAAG is less than 1.1 g/dl
consider other causes of ascites
grade 1 (mild ascites)
only detected on ultrasound
grade 2 (moderate ascites)
moderate symmetric dissension of the abdomen
grade 3 (large/gross ascites)
marked distention of the abdomen
treatment is recommended for what classifications of ascites?
only grades 2 and 3
responsive ascites
can be resolved or limited to grade 1 with diuretic therapy with/wo dietary sodium restriction
recurrent ascites
recurs on at least 3 occasions within 12 months despite treatment
refractory ascites
cannot be mobilized or unpreventable early recurrence
treatment recommendations for ascites
NO alcohol
sodium restriction (less than 2g/day)
if severe hyponatremia - restrict fluids
recommended diuretic therapy for ascites
spironolactone with/wo furosemide in 100:40 ratio
goal of diuretic therapy for ascites
attain weight loss of 0.5 kg/day
in patients with active bleeds, HE, or renal dysfunction, it may be necessary to
withhold diuretics
what to monitor when treating ascites with diuretics?
sodium
body weight
SCr
what is the drug of choice for ascites?
spironolactone
an ADR of spironolactone is __________ and if this occurs, it should be switched to ___________-
painful gynecomastia
amiloride or eplerenone
tense ascites
ascites with large volume of fluid
limits activities of daily life
for large volume paracentesis, administer
albumin 6-8 g/L of fluid removed
for tense ascites, after abdominal paracentesis, start
sodium restriction and diuretics
medications to avoid in ascites
ACEIs
ARBs
NSAIDs
amino glycoside antibiotics
avoid ___________ in refractory ascites
ACEIs and ARBs
refractory ascites
unresponsive to Na restriction and high dose diuretics
recommendations for refractory ascites
continue dietary sodium restriction
restrict fluids if hyponatremia
stop ACEIs/ARBs
serial therapeutic paracentesis
refer for liver transplantation
consider TIPS
peritoneovenous shunt
diagnosis of SBP
ascitic fluid polymorphonuclear leukocyte over 250/mm3
no evidence of alternative source of infection
suspect SBP in patients with ascites presenting with
signs and symptoms of infection
therapy for community acquired SBP
third generation cephalosporin (cefotaxime, ceftriaxone)
therapy for hospital acquired SBP, critically ill/ICU admission
broad spectrum needed based on local resistance patterns
what should be done 48 hours after starting an antibiotic for SBP?
repeat diagnostic paracentesis to assess response to antibiotics
when on antibiotics for SBP, if PMN decreases over 25%,
patient is responding to antibiotics
when on antibiotics for SBP, if PMN decreases under 25%
broaden antibiotics and assess for secondary infection
duration of antibiotics for SBP
5-7 days
after culture results for SBP,
narrow antibiotic therapy
when should albumin be added for SBP management?
patients with PMN over 250 cells/ml plus renal or liver dysfunction
who should receive one term prophylaxis for SBP?
all patients with a previous episode of SBP
long term prophylaxis for SBP should be considered for patients with ______ protein ascites and at least 1 of the following:
low
SCr > 1.2 mg/dl
BUN > 25 mg/dl
SNa < 130 mEq/L
Child-Pugh score > 9 with bilirubin > 3 mg/dl
who should receive short term prophylaxis for SBP?
patients with acute variceal bleed for up to 7 days
oral agents for long term prophylaxis of SBP
ciprofloxacin
bactrim
rifaximin
Short term prophylaxis for variceal bleeding
IV ceftriaxone
______________ levels assist in diagnosis of HE
venous ammonia
diagnosis of HE is a diagnosis of
exclusion
classifying HE by underlying disease
type A - acute liver disease
type B - portosystemic bypass
type c - cirrhosis
classify HE by time course
episodic HE
recurrent HE - multiple HE episodes within 6 months
persistent HE - always present
classify HE by presence of precipitating factors
nonprecipitated
precipitated
goal of HE treatment
reduce ammonia levels
how to reduce ammonia for HE?
decrease protein intake
decrease ammonia/nitrogenous load via gut
decrease ammonia/nitrogenous load via gut
lactulose
lactulose and PEG3350
Zinc
neomycin, metronidazole, rifaximin
nonpharmacologic therapy for HE
minimize protein intake
when HE episode resolve initiate 1.2-1.5 g/kg/day of protein
avoid precipitating factors
first line treatment for HE
lactulose
when using lactulose, you want to titrate to _________ soft stools per day
2-3
side effects of lactulose
flatulence
abdominal cramping
excessively sweet taste
If HE recurs while on lactulose, ______________ to prevent further recurrence
add rifaximin 550 mg PO BID
other treatments for HE
PEG3350
Zinc acetate
flumazenil
bromocriptine
metronidazole or neomycin
which treatment for HE is only when there is suspected benzodiazepine use?
flumazenil
systemic complications of cirrhosis
hepatorenal syndrome
hepatopulmonary syndrome
coagulation disorders
endocrine dysfunction
