Cumulative Final - Hepatology (Isaacs) Flashcards
What are true markers for liver function?
AST
ALT
Alk phos
Estimated incidence of DILI
The estimated incidence of DILI is 14-19 cases per 100,000 people
Mechanisms/classifications of different types of DILI?
Direct hepatotoxicity, idiosyncratic hepatotoxicity, and indirect hepatotoxicity
What medications are highest risk for causing DILI (See Table 3)?
Acetaminophen and anti-infectives (isoniazid, beta lactam antibiotics, fluoroquinolone antibiotics, macrolide antibiotics)
What is considered high doses of APAP?
> 8 grams acetaminophen
High doses of APAP can result in toxic levels of _____
NAPQI (can cause direct hepatotoxicity)
Tx for APAP DILI
Reverse toxic metabolite with NAC (if in grey part on graph) – binds NAPQI
Activated charcoal (if < 2H since ingestion)
What do we monitor for APAP DILI?
AST
ALT
S/Sx of OD
NAC SE
N/V, GI issues
** If pt cannot handle these, give IV NAC
What should be done if APAP DILI was intentional OD?
Psych evaluation is appropriate and monitor for s/sx of depression
What is cirrhosis?
Severe, chronic, irreversible fibrosis of the liver
1 causative factor of cirrhosis in the US
Chronic alcohol use
What is a unique symptom for someone with cirrhosis?
Jaundice
Other symptoms of cirrhosis
Weight loss
Ascites
Jaundice
-megaly
Encephalopathy (confusion)
How is cirrhosis diagnosed?
Liver biopsy
What values do we look at to determine severity of cirrhosis?
Bilirubin
Albumin
Ascites
Encephalopathy
Prothrombin time
(all part of the child-pugh score)
What model do we look at for assessing the severity of cirrhosis?
MELD (predicts 3-month mortality)
**Used in transplant prioritizations
**Not used to adjust medications
Is cirrhosis reversible?
NO!!!!
What are ascites?
Fluid accumulation in the peritoneal space
What medication class should we avoid in patients with cirrhosis?
NSAIDs
Non-pharm options for ascites management
Na+ restriction (< 2 grams/day)
Assess MELD score
First line option for ascites
Aldosterone antagonist (spironolactone) + loop diuretic (furosemide)
Recommended ratio of spironolactone: furosemide
100:40
Max ratio of spironolactone:furosemide
400:160
Second line option for ascites management
Paracentesis
TIPS
Aldosterone antagonists _____ potassium and loop diuretics ____ potassium levels
Increase
Decrease
Both, spironolactone and furosemide, can cause
AKI
What is given for pts that get more than 5 L removed via paracentesis?
ALBUMIN (helps retain fluid in vasculature)
If more than 5L is removed via paracentesis, how much albumin do we give?
6-8 g/L of fluid removed of 25% albumin
What is monitored for ascites tx?
S/Sx of ascites
Renal function
Potassium (goal: 3.5-5)
What are esophageal varices?
Compensatory “varices” or small offshoots
-Dilation of EV can cause variceal bleeding
Variceal bleeding prophylaxis
NSBB
EVL
CHOOSE 1 OR THE OTHER
Titrate NSBB to a HR goal of ____, but maintain a SBP ____
< 60 bpm
> 90 mmHg
NSBB options for EV
Nadolol
Propranolol
Carvedilol
Are PPI recommended for variceal bleeding?
NO; only used in non-variceal bleeding
Upon presentation of EV bleeding, what should be done?
- Transfusion (Hgb > 7)
- Octreotide 2-5d
- Ceftriaxone 7d
***Until we can get surgery
What surgery is done for EV bleed?
EVL
After EVL, what is done?
Secondary prophylaxis with NSBB AND EVL
Underlying patho of HE
Ammonia accumulation – leads to neuronal dysfunction and HE
S/Sx of HE
Jaundice precedes delirium, convulsions
Recommended tx for acute management of HE
Lactulose 25 ml BID
We adjust lactulose to ___ BM/day
3
Diagnosis for SBP
Therapeutic paracentesis
**PMN > 250 cells/mm3
PMN equation
PMN = WBC from fluid x (% neutrophils)
SBP tx
Ceftriaxone IV x 7d + Albumin IV
After intial tx for SBP, what is secondary prophylaxis protocol?
Bactrim (SMX/TMP) QD indefinitely
Ciprofloxacin QD
