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Acute Care II > Cirrhosis & Hepatic Failure > Flashcards

Cirrhosis & Hepatic Failure Flashcards

1
Q

Acute Liver Failure
Definition & Diagnosis

A

INR >/= 1.5
Any degree of mental alteration (encephalopathy) w/o pre-existing cirrhosis & illness < 26 weeks

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2
Q

Most common causes of acute liver failure

A

drug-induced
viral hepatitis
autoimmune
shock

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3
Q

What is the leading cause of acute liver failure?
How much is required?
What will labs reflect?

A

Acetaminophen
>10gm/d
very high LFTs low bilirubin

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4
Q

What can cause acute liver failure if ingested?
What symptoms can this cause?

A

Wild mushrooms
N/V, diarrhea, abdominal cramping, hours - 1 day after ingestion

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5
Q

Infectious causes of Acute Liver Failure

A

Hepatitis A, B, other viral hepatitis (infreq.)

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6
Q

Other uncommon causes of acute liver failure

A

Acute fatty liver of pregnancy
Reye’s Syndrome
Wilson’s Disease
Acute ischemic liver injury (shock liver)
Budd-Chiari Syndrome (rare)

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7
Q

Wilson’s disease is characterized by what?
Lab values will look like what?
Happens to what population?
Hemolytic anemia leads to what?

A

Copper accumulation
very high bili; low alk phos (bili:alk phos ratio > 2)
younger age
bili > 20 mg/dL, Keyser-Fleischer rings on slit lamp exam, elevated copper in blood, urine, & liver

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8
Q

Acute ischemic liver injury (shock liver) will display what labs?

A

markedly elevated LFTs, LDH (necrosis) with rapid improvement

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9
Q

Budd-Chiari Syndrome is characterized by what?

A

occlusion of hepatic veins

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10
Q

Acute Liver Failure Physical Exam should check what?

A

Mental Status
+/- jaundice
RUQ tenderness
enlarged liver (acute viral hepatitis, malignancy, CHF, acute Budd-Chiari syndrome)

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11
Q

Stage 1 of Acetaminophen toxicity
Time?
Liver effects?
S/Sx?

A

0-24 hrs
Preclinical
General malaise, N/V. diffuse abd pain, possibly asymptomatic, minimal s/sx, normal liver function tests, possibly

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12
Q

Stage 2 of Acetaminophen toxicity
Time?
Liver effects?
S/Sx?

A

24-72 hrs
Hepatotoxicity
RUQ pain possibly, clinically asymptomatic possibly, AST and ALT begin to rise, and possibly bilirubin, coagulopathy studies (PT, PTT, INR) may increase if severe injury

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13
Q

Stage 3 of Acetaminophen toxicity
Time?
Liver effects?
S/Sx?

A

72-96hrs
Hepatic failure with encephalopathy
LFT peak, clinical s/sx of liver failure are evident, including: jaundice, vomiting, GI upset, coagulopathy, encephalopathy, metabolic acidosis, pancreatitis possibly, acute renal failure possibly

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14
Q

Stage 4 of Acetaminophen toxicity
Time?
Liver effects?
S/Sx?

A

> 96hrs
Survival or death
Full resolution of hepatotoxicity or Multi-organ failure and death

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15
Q

Cerebral edema
Develops in what % of FHF with grade IV encephalopathy?
NH4 level < 75: rarely develops what?
>100: risk factor for what?
> 200: associated with what?
leading cause of what in FHF?
Results from what?

A

65-75%
ICH
high grade encephalopathy
cerebral herniation
death
ammonia’s direct/indirect toxic effects on the brain

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16
Q

Acute Liver Failure Lab Work up includes?

A

PT/INR
Chem: CMP, GGT, total bili, albumin creatinine
ABG
Lactate
CBC
Blood type and Screen
Acetaminophen level
Tox screen
Viral hepatitis serologies
Ceruloplasmin level
pregnancy test
ammonia level
autoimmune markers
HIV 1&2
Amylase and lipase

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17
Q

Viral hepatitis serologies include?

A

Anti-HAV IgM
HBsAg
anti-HBc IgM
anti-HEV
Anti-HCV
HCV RNA
HSV IgM
VZV

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18
Q

Autoimmune Markers include?

A

ANA
ASMA
Immunoglobulin levels

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19
Q

Viral Hepatitis
ALT/AST
Bilirubin
Alk phos
albumin
INR

A

-
decreased
increased

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20
Q

ETOH hepatitis
ALT/AST
Bilirubin
Alk phos
albumin
INR

A

-
-
Increased

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21
Q

Biliary obstruction
ALT/AST
Bilirubin
Alk phos
albumin
INR

A

-
Elevated
elevated
-
-

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22
Q

Cirrhosis
ALT/AST
Bilirubin
Alk phos
albumin
INR

A

-
decreased
elevated

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23
Q

Wilson Dz
ALT/AST
Bilirubin
Alk phos
albumin
INR

A

-
Elevated
decreased
-
-

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24
Q

Acetaminophen toxicity
ALT/AST
Bilirubin
Alk phos
albumin
INR

A

elevated
decreased
-
-
elevated

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25
Q

When etiology of ALF cannot be determined after routine evaluation do what?
It may ID what?

A

Liver bx
malignancy, autoimmune hepatitis, viral infection, wilson dz

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26
Q

Management of Acute Liver Failure
Hospital admission if?
ICU admission if?

A

any alteration in mental status
any degree of encephalopathy & referral to transplant center

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27
Q

Acetaminophen toxicity management If < 8 h after ingestion
Give what? for how long?
If labs abnormal do what?

A

N-acetylcycseine 150mg/kg/h x 1h –> 12.5mg/k/h x 20 hr –> if acet level is 0, LFTs NL, and patient is well DC
Continue @ 12.5mg/kg/h until lab & clinical improvement (50% decrease in LFTs from peak, INR < 2)

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28
Q

Acetaminophen toxicity management If > 8 h after ingestion
Give what? for how long?
If labs abnormal do what?

A

N-acetylcysteine 150mg/k/hr x1 hr –> 12.5mg/k/h x >/=36h –> if ace level 0, LFTs NL, and patient is well DC
continue @ 12.5 mg/k/hr until lab & clinical improvement (50% decrease in LFTs from peak, INR < 2)
tox consult

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29
Q

Severe or acute encephalopathy
Admit where?
Give what?

A

ICU
lactulose
rifaximin

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30
Q

Lactulose
how effective when compared to chronic encephalopathy?
How does it work?
Goal is what?

A

less effective
increases stool acidity, trappin NH4 ions
~800-1000ml of stool/day

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31
Q

Rifaximin reduces ammonia production by what means?

A

reducing ammonia producing colonic bacteria

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32
Q

Cerebral Edema Management
reduce what?
Increase what?
what type of monitoring?
Maintain CPP of what?
Support other organ systems such as?
Give what in early encephalopathy?

A

stimulation
serum osmolality (HTN saline, mannitol)
+/- ICP monitoring
> 60 mmHg
acid/base, electrolyte, dialysis, ventilator, ect.
lactulose

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33
Q

Liver Transplant Criteria for Status 1 listing (in addition to care in ICU include 1 of the following:

A

vent dependence
hemodialysis or hemofiltration
INR > 2 in pt with onset of hepatic encephalopathy w/n 8 wks of initial symptoms of liver dz

34
Q

Outcomes in ALF are worse in 1st postop year compared to recipients w/ chronic liver dz d/t what?
Beyond 1 yr how are their survival rates compared to chronic liver dz?

A

infectious & neuro complications
they surpass survival rates for chronic liver dz

35
Q

Compensated Cirrhosis
s/sx

A

usually asymptomatic

36
Q

Uncompensated Cirrhosis
s/sx

A

ascites (most freq sign)
variceal bleeding
encephalopathy

37
Q

Some Causes of Cirrhosis include?

A

ETOH
Chronic Viral Hepatitis (B/C)
NASH
Primary biliary cirrhosis
Primary sclerosing cholangitis
Autoimmune hepatitis
Hereditary hemochromatosis
Wilson Dz
Alpha-1-antitrypsin deficiency

38
Q

Cirrhosis Physical findings include

A

variable
palmer erythema
gynecomastia
splenomegaly
ascites
caput medusa
jaundice
Spider aniomata
dupuytren’s contracture
asterixis
muscle wasting
edema
encephalopathy

39
Q

Cirrhosis abdominal exam includes

A

+/- pain
distention & visible dilation of collateral veins c/w advanced dz
ascites
Fluid wave on percussion
shifting of tympanic to dull sound

40
Q

Cirrhosis Liver exam
Normally spans how far in MC line?
May be diminished in? or large in?
borders should be what? felt up to how fare below R costal margin?
Feels how in cirrhosis? feels how in acute viral hepatitis?

A

6-12cm
cirrhosis; CHF, NASH, viral hepatitis
smooth; 2cm
hard, irregular; tender enlarged smooth

41
Q

Spleen
Splenomegaly: dullness b/t where?
Palpable spleen tip suggests what?

A

9-11th ribs L midaxillary line
portal HTN

42
Q

Other S/Sx of Cirrhosis?

A

fatigue, anorexia
pruritus (cholestatic d/os like: PBC, PSC, acute/chronic hepatitis)
Rales, JVD suggests CHF, pericardial dz
peripheral edema in decompensated cirrhosis

43
Q

Cirrhosis Lab Work up
LFT?
Alk phos?
GGT
Bilirubin?
Albumin?
PT/INR?
Sodium?
Platelets?

A

mild-mod elevation
elevated
elevated
may be subtle; rises with progression
may be subtle; decreases
increased
hyponatremia
thrombocytopenia (< 150,000; most sensitive/specific in chronic dz)

44
Q

ETOH Hepatitis
Disproportionate elevation of AST compared to ALT (what ratio) with both values being?

A

2:1
< 300

45
Q

Primary Biliary Cirrhosis Hallmark sign is?

A

anti-mitochondrial antibodies (AMA) in serum

46
Q

Primary Sclerosis Cholangitis
H/o?
Cholangiogram show?

A

UC/IBD
diffuse strictures

47
Q

Autoimmune Hepatitis
Hyperglobulinemia with specific autoantibodies which include?
What can assist in diagnosis?

A

ANA, Anti-smooth muscle, antiactin
Liver bx

48
Q

Hereditary hemochromatosis
Fasting transferrin saturation >/= what in men? & >/= what in women?
Plasma ferritin concentration is > what in men & > what in women?
Requires what type of testing?
What can diagnose?

A

60% in men; 50% in women
300ng/mL in men & 200 ng/mL in women
genetic
liver bx

49
Q

Alpha-1 Antitrypsin deficiency
Clinical/biopsy suspicion
Check what? confirm with what?

A

serum AAT concentrations
phenotyping

50
Q

Viral Hepatitis
ALT/AST
Bilirubin
Alk phos
Albumin
INR

A

-
decreased
increased

51
Q

ETOH hepatitis
ALT/AST
Bilirubin
Alk phos
Albumin
INR

A

-
-
Increased

52
Q

Biliary obstruction
ALT/AST
Bilirubin
Alk phos
Albumin
INR

A

-
Increased
increased
-
-

53
Q

Cirrhosis
ALT/AST
Bilirubin
Alk phos
Albumin
INR

A

-
decreased
increased

54
Q

Wilson Dz
ALT/AST
Bilirubin
Alk phos
Albumin
INR

A

-
Increased
decreased
-
-

55
Q

Acetaminophen Tox
ALT/AST
Bilirubin
Alk phos
Albumin
INR

A

Increased
decreased
-
-
-

56
Q

Diagnostics & imaging include?

A

Biopsy (gold standard)
U/S
CT
MRI (small liver with nodular contour, splenomegaly, collateral vessels)
Trans-jugular pressure measurements
Endoscopy (screen for varices in cirrhosis to determine need for hemorrhage prophylaxis)

57
Q

Trans-jugular pressure measurements
to assess cause of what? and need for?
Hepatic venous pressure gradient is the gradient between?
NL is what? and is present if cause of portal HTN is what?
>/= what predicts complications of portal HTN?

A

portal HTN, med titration
wedged hepatic venous pressure: free hepatic/IVC pressure)
3-5; if pre-hepatic or pre-sinusoidal
10

58
Q

Biomarkers and complications associated with increased risk of decompensation and death
Low risk
Platelet count?
Liver stiffness?
Hepatic venous pressure gradient?

A

> /= 150 x 10^9/L
<10kPa
<5mmHg

59
Q

Biomarkers and complications associated with increased risk of decompensation and death
Indeterminant risk
Platelet count?
Liver stiffness?
Hepatic venous pressure gradient?

A

110-149 x 10^9/L
10-19 kPa
5-9 mmHg

60
Q

Biomarkers and complications associated with increased risk of decompensation and death
High risk
Platelet count?
Liver stiffness?
Hepatic venous pressure gradient?

A

< 110 x 10^9/L
>/= 20 kPa
>/= 10 mmHg

61
Q

Variceal Bleeding management includes?

A

Variceal band ligation
IV octreotide
Antibiotics
nonselective Beta-blockers

62
Q

Ascites Management includes?

A

Aldosterone antagonists
diuretics
TIPS

63
Q

Spontaneous Bacterial peritonitis management includes?

A

antibiotics
albumin

64
Q

Hepatorenal syndrome includes?

A

Terlipressin
norepinephrine

65
Q

Hepatic Encephalopathy Management includes?

A

Lactulose
Rifaximin
High-protein diet

66
Q

Compensated Cirrhosis
Synthetic function?
Portal pressure is where?
commonly patients are?
they may or may not have?

A

mostly NL
below threshold required for varices/ascites
fatigue
varices

67
Q

Cirrhosis management is directed @ what?
tx includes?
Caloric intake required? protein?

A

prevention of decompensation
underlying dz (antivirals, avoid ETOH, meds, screening for varices & HCCA)
25-35 kcal/kg/d; 1-2g/k/d

68
Q

Decompensated Cirrhosis
Portal HTN increased resistance to portal flow from what? leads to what?
and what?

A

fibrosis, vasoconstriction –> splenomegaly
liver insufficiency

69
Q

Ascites Management
First line treatment in patients with cirrhosis and grade 2 ascites includes?
Is fluid restriction necessary?
What should be monitored regularly when patients are receiving diuretics?
What is the first line treatment for Grade 3 ascites? after treatment what should be started?
Referral for what should be considered in patients with grade 2 or 3 ascites?
Drugs to avoid in patients with ascites include?

A

moderate sodium restriction (2g or 90 mmol/day) and diuretics (spironolactone w/ or w/o furosemide)
only if there is concomitant moderate or severe hyponatremia
body weight and serum creatinine and sodium
Large Volume Paracentesis; sodium restriction and diuretics
Liver transplant
NSAIDs

70
Q

Primary Prophylaxis for “high risk varices”: small varices with red signs or Child-Pugh C is what?
Med or Lg varices is what?
Bleeding varices?

A

Non-selective beta blockers (propranolol, nadolol, carvedilol)
NSBB or endoscopic band ligatio
NSBB + EBL for secondary prophylaxis

71
Q

Management of Pts with Mod/Large Varices That Have not Bled
Propranolol
Recommended dose?
Adjust how frequently?
Maximal daily dose?
Therapy Goals are: HR? SBP?
Follow up: check what at every outpatient visit? Continue how long? when to do EGD?

A

20-40 mg PO BID
q2-3 days until treatment goal is achieved
320mg/day in patients w/o ascites; 160mg/day in patients with ascites
Resting HR of 55-60 bpm; SBP shouldnt decrease < 90 mmHg
make sure HR is on target, continue indefinitely, no need for follow up EGD

72
Q

Management of Pts with Mod/Large Varices That Have not Bled
Nadolol
Recommended dose?
Adjust how frequently?
Maximal daily dose?
Therapy Goals are: HR? SBP?
Follow up: check what at every outpatient visit? Continue how long? when to do EGD?

A

20-40mg PO daily
q2-3 days until treatment goal achieved
160mg/day in patients w/o ascites; 80mg/day in patients with ascites
Resting HR of 55-60 bpm; SBP should not decrease < 90 mmHg
Make sure HR is on target, continue indefinitely, no need for follow up EGD

73
Q

Management of Pts with Mod/Large Varices That Have not Bled
Carvedilol
Recommended dose?
Adjust how frequently?
Maximal daily dose?
Therapy Goals are: HR? SBP?
Follow up: check what at every outpatient visit? Continue how long? when to do EGD?

A

Start w/ 6.25mg PO daily
after 3 days increase to 6.5 mg PO BID
12.5mg/day (except in patients with persistent arterial HTN)
SBP should not decrease < 90 mmHg
Continue indefinitely, no need for follow up EGD

74
Q

Acute GI bleeding + portal HTN
Initial assessment includes?
Immediate start of drug therapy includes?
Antibiotic prophylaxis includes?

A

Hx, PE, Blood exam, cultures, resuscitation
somatostatin/terlipressin
ceftriaxone or norlaxacine

75
Q

Vasoactive agents used in the management of acute variceal hemorrhage
Octreotide
Initial bolus?
Continuous infusion?
Duration?

A

50mcg (can be repeated in first hour if ongoing bleeding)
50mcg/hr
2-5 days

76
Q

Vasoactive agents used in the management of acute variceal hemorrhage
Vasopressin
Continuous infusion?
Should be accompanied by?
Duration?

A

0.2-0.4 U/min; can be increased to 0.8 U/min
IV nitro at a starting dose of 40mcg/min, wich can be increased to a max of 400mcg/min to maintain sbp of 90 mmHg
24 hrs

77
Q

Vasoactive agents used in the management of acute variceal hemorrhage
SMT
Initial bolus?
Continuous infusion?
Duration?

A

250mcg (can be repeated in the first hr if ongoing bleeding)
25-500mcg/hr
2-5 days

78
Q

Vasoactive agents used in the management of acute variceal hemorrhage
Terlipressin (VP analogue)
Initial 48hrs?
Maintenance?
Duration?

A

2mg IV q 4 hr until control of bleeding
1mg IV q 4 hr to prevent rebleeding

79
Q

Encephalopathy
NH3 accumulation d/t what/
Hallmark sign is?
look for what?
ID what? & correct
Empirical tx includes?
Daily energy intake should be?
Daily protein intake should be?

A

reduced liver metabolism
asterixis
other causes of AMS
precipitating factors
lacutlose & rifaximin
35-40 kcal/kg IBW
1.2-1.5g/kg/day

80
Q

Encephalopathy empirical tx
Lactulose
increases stool what?
Dose?
Goal?

A

H2O content, acidity, traps NH4 ions
30-45ml TID-qid
2-3 soft stools/d

81
Q

Encephalopathy empirical tx
Rifaximin
Diminishes enteric bacteria which leads to?
Dose?

A

decreased production of nitrogenous compounds
550mg BID

82
Q

Liver Dz Scoring Systems

A

Child-Pugh
MELD

Acute Care II (12 decks)

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