complications of liver disease Flashcards
what are 3 complications of liver disease
ascites (SBP) , varices, encephalopathy
primary prevention for variceal hemorrhage
non-selective beta blockers: nadolol, propranolol, carvedilol
how to titrate beta blocker dose
every 2-3 days to maximum tolerated dose, HR 55-60 bpm and BP >90/60 mmHg
whats the beta blocker duration
indefinite
general treatments for acute variceal bleed
IV fluids, blood transfusions, vasoconstriction + endoscopic therapy, short term antibiotics
which IV fluids are preferred for acute variceal bleed
NS, LR
blood transfusions maintain hemoglobin > ___
8 gm/dL
how many days should you do a vasoconstriction agent
5
what are the vasoconstriction agents
octreotide and vasopressin
which vasoconstriction agent is preferred
octreotide
how many days should you do antibiotics for acute variceal bleed
7
what antibiotics are preferred for acute variceal bleed
3rd generation cephalosporins, alternative is fluoroquinolones. start IV then switch to PO
octreotide dose?
IV bolus 25-100 mcg, continuous 25-50 mcg/hr
octreotide adverse
bradycardia, hypertension, nausea, abdominal cramps, diarrhea, malabsorption of fat, hyperglycemia
vasopressin dose?
0.2-0.4 units/min IV infusion (max 0.8 units/min)
vasopressin adverse
hypertension, severe headache, coronary and mesenteric ischemia, bowel ischemia, non-selective vasoconstriction
therapy for secondary prevention of variceal hemorrhage
non-selective BB titrated to achieve a goal HR of 55-60 bpm or the maximal tolerated dose PLUS endoscopic variceal ligation q1-2weeks until obliteration, followup 3-6mo then q6-12mo
how to calculate SAAG (serum ascites albumin gradient)
serum albumin-ascitic albumin
if SAAG is > ___, the patient almost certainly has portal hypertension
1.1 g/dL
general treatment approaches to ascites
sodium restriction, diuretics, therapeutic paracentesis, abstinence from alcohol
how should sodium be restricted with ascites
<2 grams per day
how should you give diuretics for ascites
spironolactone PLUS furosemide (100:40)
what fluids should you give for therapeutic paracentesis for ascites
if >5 L removed, give 6-8 gm 25% albumin as IV infusion per 1 L ascites removed
when should you do fluid restriction with ascites
only in severe hyponatremia (Na <125)
if the patient cannot tolerate spironolactone + furosemide, which one is preferred
spironolactone
spironolactone dosing
initial dose 100 mg, max dose 400 mg/day
spironolactone concerns?
hyperkalemia, gynecomastia, lower extremity cramps, increase in SCr and BUN
furosemide dosing
initial dose 40 mg/day, max dose 160 mg/day
furosemide concerns
electrolyte imbalance, SCr, BUN, lower extremity cramps
initial goal of diuretic therapy
daily weight loss of 0.5 kg until patient is euvolemic
how often to up-titrate diuretic dose
every 3-5 days
how long to give diuretics
typically lifelong
when to discontinue or hold diuretic therapy
uncontrolled encephalopathy, severe hyponatremia (Na <120) despite fluid restriction, renal insufficiency (SCr >2)
drugs to avoid in patients with ascites
ACEi, ARB, NSAID
options for diuretic refractory patients
midodrine 7.5 mg TID (to inc BP to allow up titration of diuretic), serial therapeutic paracentesis, liver transplant, transjugular intrahepatic portosystemic stent-shunt
symptoms of SBP?
ascites may be the only symptom. others: fever, abdominal pain, unexplained encephalopathy
most common organisms of SBP
E. coli, klebsiella, strep pneumoniae
how to diagnose SBP
diagnostic paracentesis to assess WBC count. PMN> 250 cells/mm3 is infection
how to calculate PMN
[WBC x (% neutrophils + % bands)]
should you wait for SBP culture before initiating antibiotics
NOPE
1st line for SBP treatment
cefotaxime 2 gm IV q8h x 5d, ceftriaxone 2 gm IV q24 h x 5 days
second line for SBP treatment
cipro 400 mg IV or 500 mg PO q12h x 8 days, ofloxacin 400 mg PO q12h x 8 days
when do you give SBP patient albumin
if SCr>1, BUN>30, or bilirubin >4
how do you give albumin for SBP
albumin 25% IV infusion 1.5 g/kg on day 1 and 1 g/kg on day 3
why do you give albumin for SBP
improved survival
when do you give SBP indefinite prophylaxis
SBP infection, or ascitic protein <1.5 and one of the following: SCr >1.2, BUN>25, Na <130, child pugh C with bilirubin >3
what do you give for indefinite prophylaxis
SMX-TMP or cipro daily
what is the dose for SBP prophylaxis during GI bleeding
ceftriaxone 1 gm IV q24h x 7d, cefotaxime 1 gm IV q8h x 7d. can switch to oral bactrim DS BID or cipro 500 BID once the patient is stable and eating
alternatives for SBP prophylaxis during GI bleeding
cipro 400 mg IV q12h, cipro 500 mg po q12h
mechanism of lactulose for HE
causes a laxative effect that reduces the time period available for ammonia absorption, metabolized by gut flora into acetic acid and lactic acid which lowers colonic pH and traps NH3 in colon as NH4+
dose for episodic HE
30 mL PO q1-2h until evacuation
dose for chronic HE
15-45 mL PO q8-12h, titrated to 2-3 SOFT stools daily
lactulose side effects
severe diarrhea, electrolyte disturbances, hypovolemia
lactulose counseling points
abdominal distention, bloating, take with or without food, full glass of water, juice or milk improve taste, can be used in feeding tubes (dilute with water and flush tube before)
PEG 3350 dose
255 gm in 4 L ONCE: not for use in chronic
PEG side effects
cramping, electrolyte disturbances
antibiotics for HE MOA
reduce NH3 forming bacteria in colon
rifaximin dose
550 mg PO BID or 400 mg PO TID
