Complications of Cirrhosis Flashcards
Management of Ascites
- Most frequent complication of cirrhosis
- Goals of treatment
1) Minimize fluid overload to minimize risk of infection
2) Improve patients quality of life
Treatment of Ascites
-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)
Overdiuresis
- Can potentiate renal failure
- Aggressive diuresis needs to be monitored
- In ambulatory (home) setting spironolactone as mono therapy is preferred
Side effects of diuretics
- Renal impairment due to volume depletion
- Hyponatremia (loss of salt)
- Hepatic encephalopathy
- Hyperkalemia
Paracentesis
- Super big ascites
- Drain them with a needle
- Can lead to infection
Paracentesis induced circulatory dysfunction (PICD)
- 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)
Hepatic Encephalopathy
- Confusion/disorientation due to a build up of toxins
- Exact mechanism is unknown
- Go to treatment: Lactulose
Hepatic Encephalopathy Treatment
- 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
Rifaximin (Xifaxan)
- Antibiotic for prophylaxis of Hepatic encephalopathy (HE)
- Better tolerated and faster onset than lactulose
- Expensive though
Variceal bleeds
- Medical emergency
- Requires endoscopic evaluation
- Goal: stop the bleed, prevent rebleeding
Treatment for variceal bleeds
- For acute bleed: Octreotide for 3 to 5 days (decreases bp, decreasing bleeding)
- Endoscopic evaluation (EGD) ties varices to stop the bleeding
Primary Prophylaxis
- Antibiotic prophylaxis
- to prevent infection and rebleed
- MUST have gram negative coverage
ex. Ciprofloxacin, Ceftriaxone, Cefotaxime
Volume resuscitation
- 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
Prevention of Variceal bleeds
- 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)
Why is the spleen important
- Largest lymphoid organ
- Helps with clearance of encapsulated bugs (S. pneumoniae)
- Portal hypertension can lead to splenomegaly
Spontaneous Bacterial Peritonitis (SBP)
-Infection of ascitic fluid without evidence of abdominal source
SBP risk factors
- Prior episode
- Variceal bleed
- Ascitic fluid protein <1g/dL
- Total bilirubin > 2.5mg/dL
- Use of PPIs
- Main culprit: enterobacteriaceae (E. coli, K. pneumonia)
Diagnosing SBP
- Fever, abdominal pain, encephalopathy
- Ascitic fluid culture
- PMN>250/mm^3 = treat
- Treat with Cefotaxime or Ceftriaxone
Secondary prophylaxis in SBP
- Bactrim
- Ciprofloxacin
- Levofloxacin
Renal effects of Cirrhosis
- 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
Acute kidney injury due to Cirrhosis
1) Renal hypoperfusion- vomiting, diarrhea, sepsis
2) Acute tubular necrosis- direct insult to the kidneys, usually drug related (NSAIDs, Aminoglycosides)
Hepatorenal syndrome
- Liver is messed up
- Kidneys try and pickup the slack
- Then they both end up messed up
Treatment of Hepatorenal syndrome
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
Bleeding risk due to Cirrhosis
- 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
