Cirrhosis & Hepatic Failure Flashcards
Compensated Cirrhosis
s/sx
usually asymptomatic
Uncompensated Cirrhosis
s/sx
ascites (most freq sign)
variceal bleeding
encephalopathy
Some Causes of Cirrhosis include?
ETOH
Chronic Viral Hepatitis (B/C)
NASH
Primary biliary cirrhosis
Primary sclerosing cholangitis
Autoimmune hepatitis
Hereditary hemochromatosis
Wilson Dz
Alpha-1-antitrypsin deficiency
Cirrhosis Physical findings include
variable
palmer erythema
gynecomastia
splenomegaly
ascites
caput medusa
jaundice
Spider aniomata
dupuytren’s contracture
asterixis
muscle wasting
edema
encephalopathy
Cirrhosis abdominal exam includes
+/- pain
distention & visible dilation of collateral veins c/w advanced dz
ascites
Fluid wave on percussion
shifting of tympanic to dull sound
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?
6-12cm
cirrhosis; CHF, NASH, viral hepatitis
smooth; 2cm
hard, irregular; tender enlarged smooth
Spleen
Splenomegaly: dullness b/t where?
Palpable spleen tip suggests what?
9-11th ribs L midaxillary line
portal HTN
Other S/Sx of Cirrhosis?
fatigue, anorexia
pruritus (cholestatic d/os like: PBC, PSC, acute/chronic hepatitis)
Rales, JVD suggests CHF, pericardial dz
peripheral edema in decompensated cirrhosis
Cirrhosis Lab Work up
LFT?
Alk phos?
GGT
Bilirubin?
Albumin?
PT/INR?
Sodium?
Platelets?
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)
ETOH Hepatitis
Disproportionate elevation of AST compared to ALT (what ratio) with both values being?
2:1
< 300
Primary Biliary Cirrhosis Hallmark sign is?
anti-mitochondrial antibodies (AMA) in serum
Primary Sclerosis Cholangitis
H/o?
Cholangiogram show?
UC/IBD
diffuse strictures
Autoimmune Hepatitis
Hyperglobulinemia with specific autoantibodies which include?
What can assist in diagnosis?
ANA, Anti-smooth muscle, antiactin
Liver bx
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?
60% in men; 50% in women
300ng/mL in men & 200 ng/mL in women
genetic
liver bx
Alpha-1 Antitrypsin deficiency
Clinical/biopsy suspicion
Check what? confirm with what?
serum AAT concentrations
phenotyping
Viral Hepatitis
ALT/AST
Bilirubin
Alk phos
Albumin
INR
Increased
/
/
decreased
increased
ETOH hepatitis
ALT/AST
Bilirubin
Alk phos
Albumin
INR
Increased
/
/
/
Increased
Biliary obstruction
ALT/AST
Bilirubin
Alk phos
Albumin
INR
/
Increased
increased
/
/
Cirrhosis
ALT/AST
Bilirubin
Alk phos
Albumin
INR
Increased
/
/
decreased
increased
Wilson Dz
ALT/AST
Bilirubin
Alk phos
Albumin
INR
/
Increased
decreased
/
/
Acetaminophen Tox
ALT/AST
Bilirubin
Alk phos
Albumin
INR
Increased
decreased
/
/
/
Diagnostics & imaging include?
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)
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?
portal HTN, med titration
wedged hepatic venous pressure: free hepatic/IVC pressure)
3-5; if pre-hepatic or pre-sinusoidal
10
Biomarkers and complications associated with increased risk of decompensation and death
Low risk
Platelet count?
Liver stiffness?
Hepatic venous pressure gradient?
> /= 150 x 10^9/L
<10kPa
<5mmHg
Biomarkers and complications associated with increased risk of decompensation and death
Indeterminant risk
Platelet count?
Liver stiffness?
Hepatic venous pressure gradient?
110-149 x 10^9/L
10-19 kPa
5-9 mmHg
Biomarkers and complications associated with increased risk of decompensation and death
High risk
Platelet count?
Liver stiffness?
Hepatic venous pressure gradient?
< 110 x 10^9/L
>/= 20 kPa
>/= 10 mmHg
Variceal Bleeding management includes?
Variceal band ligation
IV octreotide
Antibiotics
nonselective Beta-blockers
Ascites Management includes?
Aldosterone antagonists
diuretics
TIPS
Spontaneous Bacterial peritonitis management includes?
antibiotics
albumin
Hepatorenal syndrome management medications include?
Terlipressin
norepinephrine
Hepatic Encephalopathy Management includes?
Lactulose
Rifaximin
High-protein diet
Compensated Cirrhosis
Synthetic function?
Portal pressure is where?
commonly patients are?
they may or may not have?
mostly NL
below threshold required for varices/ascites
fatigue
varices
Cirrhosis management is directed @ what?
tx includes?
Caloric intake required? protein?
prevention of decompensation
underlying dz (antivirals, avoid ETOH, meds, screening for varices & HCCA)
25-35 kcal/kg/d; 1-2g/k/d
Decompensated Cirrhosis
Portal HTN increased resistance to portal flow from what? leads to what?
and what?
fibrosis, vasoconstriction –> splenomegaly
liver insufficiency
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?
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
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?
Non-selective beta blockers (propranolol, nadolol, carvedilol)
NSBB or endoscopic band ligatio
NSBB + EBL for secondary prophylaxis
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?
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
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?
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
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?
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
Acute GI bleeding + portal HTN
Initial assessment includes?
Immediate start of drug therapy includes?
Antibiotic prophylaxis includes?
Hx, PE, Blood exam, cultures, resuscitation
somatostatin/terlipressin
ceftriaxone or norlaxacine
Vasoactive agents used in the management of acute variceal hemorrhage
Octreotide
Initial bolus?
Continuous infusion?
Duration?
50mcg (can be repeated in first hour if ongoing bleeding)
50mcg/hr
2-5 days
Vasoactive agents used in the management of acute variceal hemorrhage
Vasopressin
Continuous infusion?
Should be accompanied by?
Duration?
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
Vasoactive agents used in the management of acute variceal hemorrhage
SMT
Initial bolus?
Continuous infusion?
Duration?
250mcg (can be repeated in the first hr if ongoing bleeding)
25-500mcg/hr
2-5 days
Vasoactive agents used in the management of acute variceal hemorrhage
Terlipressin (VP analogue)
Initial 48hrs?
Maintenance?
Duration?
2mg IV q 4 hr until control of bleeding
1mg IV q 4 hr to prevent rebleeding
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?
reduced liver metabolism
asterixis
other causes of AMS
precipitating factors
lacutlose & rifaximin
35-40 kcal/kg IBW
1.2-1.5g/kg/day
Encephalopathy empirical tx
Lactulose
increases stool what?
Dose?
Goal?
H2O content, acidity, traps NH4 ions
30-45ml TID-qid
2-3 soft stools/d
Encephalopathy empirical tx
Rifaximin
Diminishes enteric bacteria which leads to?
Dose?
decreased production of nitrogenous compounds
550mg BID
Liver Dz Scoring Systems
Child-Pugh
MELD
