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complications of liver disease Flashcards

1
Q

what are 3 complications of liver disease

A

ascites (SBP) , varices, encephalopathy

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2
Q

primary prevention for variceal hemorrhage

A

non-selective beta blockers: nadolol, propranolol, carvedilol

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3
Q

how to titrate beta blocker dose

A

every 2-3 days to maximum tolerated dose, HR 55-60 bpm and BP >90/60 mmHg

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4
Q

whats the beta blocker duration

A

indefinite

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5
Q

general treatments for acute variceal bleed

A

IV fluids, blood transfusions, vasoconstriction + endoscopic therapy, short term antibiotics

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6
Q

which IV fluids are preferred for acute variceal bleed

A

NS, LR

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7
Q

blood transfusions maintain hemoglobin > ___

A

8 gm/dL

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8
Q

how many days should you do a vasoconstriction agent

A

5

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9
Q

what are the vasoconstriction agents

A

octreotide and vasopressin

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10
Q

which vasoconstriction agent is preferred

A

octreotide

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11
Q

how many days should you do antibiotics for acute variceal bleed

A

7

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12
Q

what antibiotics are preferred for acute variceal bleed

A

3rd generation cephalosporins, alternative is fluoroquinolones. start IV then switch to PO

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13
Q

octreotide dose?

A

IV bolus 25-100 mcg, continuous 25-50 mcg/hr

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14
Q

octreotide adverse

A

bradycardia, hypertension, nausea, abdominal cramps, diarrhea, malabsorption of fat, hyperglycemia

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15
Q

vasopressin dose?

A

0.2-0.4 units/min IV infusion (max 0.8 units/min)

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16
Q

vasopressin adverse

A

hypertension, severe headache, coronary and mesenteric ischemia, bowel ischemia, non-selective vasoconstriction

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17
Q

therapy for secondary prevention of variceal hemorrhage

A

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

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18
Q

how to calculate SAAG (serum ascites albumin gradient)

A

serum albumin-ascitic albumin

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19
Q

if SAAG is > ___, the patient almost certainly has portal hypertension

A

1.1 g/dL

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20
Q

general treatment approaches to ascites

A

sodium restriction, diuretics, therapeutic paracentesis, abstinence from alcohol

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21
Q

how should sodium be restricted with ascites

A

<2 grams per day

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22
Q

how should you give diuretics for ascites

A

spironolactone PLUS furosemide (100:40)

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23
Q

what fluids should you give for therapeutic paracentesis for ascites

A

if >5 L removed, give 6-8 gm 25% albumin as IV infusion per 1 L ascites removed

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24
Q

when should you do fluid restriction with ascites

A

only in severe hyponatremia (Na <125)

25
Q

if the patient cannot tolerate spironolactone + furosemide, which one is preferred

A

spironolactone

26
Q

spironolactone dosing

A

initial dose 100 mg, max dose 400 mg/day

27
Q

spironolactone concerns?

A

hyperkalemia, gynecomastia, lower extremity cramps, increase in SCr and BUN

28
Q

furosemide dosing

A

initial dose 40 mg/day, max dose 160 mg/day

29
Q

furosemide concerns

A

electrolyte imbalance, SCr, BUN, lower extremity cramps

30
Q

initial goal of diuretic therapy

A

daily weight loss of 0.5 kg until patient is euvolemic

31
Q

how often to up-titrate diuretic dose

A

every 3-5 days

32
Q

how long to give diuretics

A

typically lifelong

33
Q

when to discontinue or hold diuretic therapy

A

uncontrolled encephalopathy, severe hyponatremia (Na <120) despite fluid restriction, renal insufficiency (SCr >2)

34
Q

drugs to avoid in patients with ascites

A

ACEi, ARB, NSAID

35
Q

options for diuretic refractory patients

A

midodrine 7.5 mg TID (to inc BP to allow up titration of diuretic), serial therapeutic paracentesis, liver transplant, transjugular intrahepatic portosystemic stent-shunt

36
Q

symptoms of SBP?

A

ascites may be the only symptom. others: fever, abdominal pain, unexplained encephalopathy

37
Q

most common organisms of SBP

A

E. coli, klebsiella, strep pneumoniae

38
Q

how to diagnose SBP

A

diagnostic paracentesis to assess WBC count. PMN> 250 cells/mm3 is infection

39
Q

how to calculate PMN

A

[WBC x (% neutrophils + % bands)]

40
Q

should you wait for SBP culture before initiating antibiotics

A

NOPE

41
Q

1st line for SBP treatment

A

cefotaxime 2 gm IV q8h x 5d, ceftriaxone 2 gm IV q24 h x 5 days

42
Q

second line for SBP treatment

A

cipro 400 mg IV or 500 mg PO q12h x 8 days, ofloxacin 400 mg PO q12h x 8 days

43
Q

when do you give SBP patient albumin

A

if SCr>1, BUN>30, or bilirubin >4

44
Q

how do you give albumin for SBP

A

albumin 25% IV infusion 1.5 g/kg on day 1 and 1 g/kg on day 3

45
Q

why do you give albumin for SBP

A

improved survival

46
Q

when do you give SBP indefinite prophylaxis

A

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

47
Q

what do you give for indefinite prophylaxis

A

SMX-TMP or cipro daily

48
Q

what is the dose for SBP prophylaxis during GI bleeding

A

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

49
Q

alternatives for SBP prophylaxis during GI bleeding

A

cipro 400 mg IV q12h, cipro 500 mg po q12h

50
Q

mechanism of lactulose for HE

A

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+

51
Q

dose for episodic HE

A

30 mL PO q1-2h until evacuation

52
Q

dose for chronic HE

A

15-45 mL PO q8-12h, titrated to 2-3 SOFT stools daily

53
Q

lactulose side effects

A

severe diarrhea, electrolyte disturbances, hypovolemia

54
Q

lactulose counseling points

A

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)

55
Q

PEG 3350 dose

A

255 gm in 4 L ONCE: not for use in chronic

56
Q

PEG side effects

A

cramping, electrolyte disturbances

57
Q

antibiotics for HE MOA

A

reduce NH3 forming bacteria in colon

58
Q

rifaximin dose

A

550 mg PO BID or 400 mg PO TID

GI (15 decks)

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