Day 4- Liver and GERD Flashcards
What are the 2 unique functions of the liver?
What do lobules in the liver do?
What does the liver do for the body?
Natural regeneration of lost tissue.. can regenerate from 25%. Dual blood supply(portal vein,Hepatic artery).
Has a portal triad(branch of portal vein, hepatic artery, bile duct). Functional unit of liver.
Blood reservoir, Carbohydrate and lipid metabolism, Protein synthesis(clotting factors, albumin, immune globulins), storage(vitamins, minerals, glycogen), endocrine functions, detoxification, bile production.
What causes liver failure?
What labs are associated with liver disease?
What are your big signs of cirrhosis?
Viral and Autoimmune hepatitis, Biliary Cirrhosis, NAFLD, Alcohol Induced, Drug Induced(leading cause of acute liver injury), Cardiac Cirrhosis, Inherited liver disease, Crytpogenic cirrohsis, Shock Liver.
Albumin, Prealbumin, PT/INR, Bilirybin, Alkaline Phosphatase, 5-nucleotidase, GGT(bile duct), AST, ALT, Ammonia.
Jaundice(Icteric Sclera), Melana, Hematochezia(bright red blood in stool), Ascites, Fetor Hepaticus, Spider Nevi, Liver flap(coarse hand tremor).
What are the Child Pugh Classification gradings to know?
What gives you 1 point on Child Pugh?
what gives you 2 points on Child Pugh?
Grade A < 7 points(1 and 2 year survival rate: 100% and 85%). Grade B < 7-9 points( 80% and 60%). Grade C: 10-15 points (45% and 35%).
<2 bilirubin, >3.5 albumin, <1.7 INR.
Mild-moderate Encephalopathy, Mild-Moderate ascites, 2-3 bilirubin, 2.8-3.5 albumin, 1.7-2.3 INR.
What gives you 3 points on Child Pugh?
What is the MELD score for?
What is the definition of Portal Hypertension?
Severe encephalopathy, large or refractory to diuretics ascites, >3 bilirubin, <2.8 albumin, >2.3 INR.
Ranking on a transplant list.
HVPG >5 mm Hg.
What happens in Variceal Bleeding?
What is primary prophylaxis for variceal bleeding?
What is your goal and duration of beta blockers for variceal bleeding?
Blood gets pushed back from portal vein into blood vessels in GI tract.
non selective beta blockers(Propanolol, Nadolol, Carvedilol), given to people with medium to large varices, small varices + risk factors, not recommended for patients without varices or with small varices without risk factors.
55-60 beats per min, duration is indefinitely until risks outweigh benefit.
What is 2nd line prophylaxis for variceal bleeding?
How do you treat Acute Variceal Hemmorhage?
What is Secondary prophylaxis for people who have already bled?
Endoscopic Variceal Ligation.
Aiming for 8 Hgb, 90-100 SBP, <100 HR. Avoid aggressive saline resuscitation. First line treatment is Ocreotide(more common)/Vasopressin–> give bolus of 50 mcg, then continuous IV of 50 mcg/h. Also use antibiotics(norfloxacin, ciprofloxacin, ceftriaxone).
Non-selective BB(carvedilol not used in this case) + EVL.
What is acute ascites treatment?
What is secondary prophylaxis for acute ascites?
What is primary prophylaxis for SBP?
Serial Paracentesis(give albumin if more than 5 liters pulled out).
Alcohol abstinence, sodium restriction, oral diuretics(spironolactone, spironolactone and furosemide). Start with 100:40 mg ratio(max 400 spirono and 160 furos).
Norfloxacin OR Bactrim.
How do you treat SBP?
What is secondary prophylaxis in all patients that have had SBP?
How do you treat Hepatic Encephalopathy?
Cefotaxime/Ofloxacin/ IV cipro AND Albumin.
Norfloxacin OR Bactrim.
Protein withdrawal and Lactulose(titrate it to 2-3 soft stools a day).
What is second line adjunct therapy for hepatic encephalopahty?
What organizations guidelines do you use for Liver guidelines?
What are the risk factors for drug induced liver disease?
Rifaximin, Can also give Neomycin and Metronidazole.
AASLD.
Chronic liver and renal disease, HIV, Obesity, Age, Occupation, Cumulative dose, Duration, Concurrent Hepatotoxic agents. Alcohol, Antibiotics, Acetaminophen.
What are your mechanisms of injury for liver disease?
How can you see hepatocellular injury?
What is Cholestatic injury?
Intrinsic Hepatoxicity(dose/duration dependant, time of onset predictable), Hypersensitivity(develops after sensitization period, eosinophilia, rash and fever), Idiosyncratic(abnormal metabolic pathway like valproic acid and isonazoid).
Interferes with metabolic processes. Most life threatening, presents with anicteric or icteric, fever, arthralgias, hepatomegaly. Implicated in methotrexate, antibiotics, anticonvulsants.
Interferes with secretory processes. Jaundice, Alcoholic stools(gray), dark urine, fever, upper right quadrant pain. Implicated in Ceftriaxone. Will see high bilirubin.
What is mixed injury liver disease?
What is Vascular injury liver disease?
What is Neoplasia liver disease?
Mixed. Yup.
Causes partial or full blood clot in liver(Budd-Chiari syndrome). Cause by oral contraceptives + additional risk factors( protein C or S deficiency, antiphospholipid syndrome, antithrombin 3 deficiency, factor V leiden mutation). Signs are acute onset ascites, weight gain, jaundice, etc.
Benign tumors found in liver, implicated drugs are anabolic steroids(6 years from initiation), oral contraceptives.
What is treatment of drug induced liver injury?
What are the risk factors for liver injury in alcohol induced liver disease?
What is treatment for alcoholic liver disease?
Discontinuation. Rechallenge? If cirrhosis or hypersensitivity. Can give supportive care for complications(pruitis, encephatlopathy, coagulopahty, SBP). NO role for corticosteroids in drug-induced hepatitis.
Dose or amount consumed, duration, type, binge drinking, sex(females higher), race(blacks or hispanics), obesity, diet in high polyunsaturated fats, iron overload, concomitant viral hepatitis infection, Genetic factors(children of alcoholics, identical twins>fraternal, polymorphisms.
Naltrexone, Acamprosate. Nutritional support.
How do you treat someone if their DF >32 and have alcoholic history?
What causes GERD?
What are risk factors for GERD?
Prednisolone daily for 28 days(then taper). Pentoxifylline(TID for 28 days).
External and internal stomach pressure, lack of adequate saliva, relaxation of LES, hyptotensive LES, Hiatal Hernia.
Large meals, Gastroperisis, Adipose Tissue, Pregnancy, Tight Clothing, Bending Over, Hiatal Hernia, Relaxation of LES.
What are medications that worsen GERD?
What are Typical GERD symptoms?
What are Atypical GERD symptoms?
QB PAIN(directly irritates esophagus), CABE DNT^2(Decreased LES pressure),Sloq gastric emptying(anticholinergics, GLP-1 agonists, Opioids).
Heartburn, regurgitation.
Chronic cough, laryngitis, asthma, dental erosions, nausea, bloating.
What are alarm symptoms for GERD?
What are non pharmacologic treatments for GERD?
What are the 3 treatment options for GERD?
Vomiting, Anemia, Chest pain, Unintended weight loss, dysphagia, epigastric mass.
Weight loss, loose clothes, elevation of head to bed, remain upright for 2-3 hours, avoid alcohol and smoking, identify possible food causes.
Antacids, H2RA, PPI.
