Complications of Cirrhosis

Question 1

Management of Ascites

Answer 1

• Most frequent complication of cirrhosis
• Goals of treatment
  1) Minimize fluid overload to minimize risk of infection
  2) Improve patients quality of life

Question 2

Treatment of Ascites

Answer 2

-Salt restriction (DASH diet)
max = 2g/day
-Diuretics
1) Spironolactone- can be effective when used alone
2) Combo therapy: Spironolactone + Furosemide (don’t use furosemide as mono-therapy)

Question 3

Overdiuresis

Answer 3

• Can potentiate renal failure
• Aggressive diuresis needs to be monitored
• In ambulatory (home) setting spironolactone as mono therapy is preferred

Question 4

Side effects of diuretics

Answer 4

• Renal impairment due to volume depletion
• Hyponatremia (loss of salt)
• Hepatic encephalopathy
• Hyperkalemia

Question 5

Paracentesis

Answer 5

• Super big ascites
• Drain them with a needle
• Can lead to infection

Question 6

Paracentesis induced circulatory dysfunction (PICD)

Answer 6

• Increase in plasma renin activity, due to decreased blood volume
• Associated with accumulation of ascites, shorter survival time, reduced renal function
• Prevent with albumin 6-10g/Liter (if fluid removal is > 5L)

Question 7

Hepatic Encephalopathy

Answer 7

• Confusion/disorientation due to a build up of toxins
• Exact mechanism is unknown
• Go to treatment: Lactulose

Question 8

Hepatic Encephalopathy Treatment

Answer 8

• Lactulose 45mL orally ever 1 to 2 hrs until loose bowl movement
• Titrate to have 2 to 3 loose bowel moements per day
• Use chronically to prevent recurrence of HE
• Enemas can be used, but lactulose PO is preferred

Question 9

Rifaximin (Xifaxan)

Answer 9

• Antibiotic for prophylaxis of Hepatic encephalopathy (HE)
• Better tolerated and faster onset than lactulose
• Expensive though

Question 10

Variceal bleeds

Answer 10

• Medical emergency
• Requires endoscopic evaluation
• Goal: stop the bleed, prevent rebleeding

Question 11

Treatment for variceal bleeds

Answer 11

• For acute bleed: Octreotide for 3 to 5 days (decreases bp, decreasing bleeding)
• Endoscopic evaluation (EGD) ties varices to stop the bleeding

Question 12

Primary Prophylaxis

Answer 12

• Antibiotic prophylaxis
• to prevent infection and rebleed
• MUST have gram negative coverage
  ex. Ciprofloxacin, Ceftriaxone, Cefotaxime

Question 13

Volume resuscitation

Answer 13

• Loss in blood causes loss in fluid volume which can lead to complications
• Start with Normal Saline
• Use blood or blood products if patients Hgb < 8g/dL

Question 14

Prevention of Variceal bleeds

Answer 14

• Decrease portal hypertension
• Use beta blockers to accomplish this
• Propranolol or Nadolol (better tolerated) titrate up until 25% drop in bp
• Selective beta blockers are less effective
• May cause issues in patients with ascites (due to altered cardiac output)

Question 15

Why is the spleen important

Answer 15

• Largest lymphoid organ
• Helps with clearance of encapsulated bugs (S. pneumoniae)
• Portal hypertension can lead to splenomegaly

Question 16

Spontaneous Bacterial Peritonitis (SBP)

Answer 16

-Infection of ascitic fluid without evidence of abdominal source

Question 17

SBP risk factors

Answer 17

• Prior episode
• Variceal bleed
• Ascitic fluid protein <1g/dL
• Total bilirubin > 2.5mg/dL
• Use of PPIs
• Main culprit: enterobacteriaceae (E. coli, K. pneumonia)

Question 18

Diagnosing SBP

Answer 18

• Fever, abdominal pain, encephalopathy
• Ascitic fluid culture
• PMN>250/mm^3 = treat
• Treat with Cefotaxime or Ceftriaxone

Question 19

Secondary prophylaxis in SBP

Answer 19

• Bactrim
• Ciprofloxacin
• Levofloxacin

Question 20

Renal effects of Cirrhosis

Answer 20

• Portal hypertension, leads to systemic hypertension which effects the kidneys
• Hypoperfusion in kidneys, activating RAAS
• RAAS activation leads to salt and water retention
• Can lead to renal failure

Question 21

Acute kidney injury due to Cirrhosis

Answer 21

1) Renal hypoperfusion- vomiting, diarrhea, sepsis

2) Acute tubular necrosis- direct insult to the kidneys, usually drug related (NSAIDs, Aminoglycosides)

Question 22

Hepatorenal syndrome

Answer 22

• Liver is messed up
• Kidneys try and pickup the slack
• Then they both end up messed up

Question 23

Treatment of Hepatorenal syndrome

Answer 23

a) Type 1: rapidly progressive, doubling of serum creatinine or 50% drop in CrCl
- Treatment: Albumin + vasopressor
b) Type 2: Slowly progressive renal injury due to systemic effects of cirrhosis
- Goal: minimize renal insult, avoid nephrotoxic agents

Question 24

Bleeding risk due to Cirrhosis

Answer 24

• Decreased clotting factor production
• Increased INR
• Treatment:
  a) vitamin K- if not effective in 3days, d/c
  b) Fresh frozen plasma (FFP)- used for acute bleed management

Question 25

Medication issues due to liver disease

Answer 25

• Tylenol
• NSAIDs
• Aspirin
• COX2 inhibitors
• Opioids
• Lots of stuff gets metabolized in the liver