ESLD Flashcards
NAFLD/MASLD Treatment
Overall Goals to Manage Cirrhosis/ESLD
- PROTECT THE LIVER FROM HARM
- Discontinue harmful medications
- Monitor blood pressure
- Avoid alcohol, NSAIDs, herbal medications, raw shellfish
- Maintain vigilance for complications of cirrhosis
- Screen for esophageal varices
- Screen for HCC every 6 months
- Refer for liver transplantation if appropriate
Portal Hypertension
- Normal pressure ~ 6 mmHg
- Clinically significant portal HTN ~ > 10-12 mmHg
CF: ascites, gastroesophageal varices, hepatic encephalopathy, hepatorenal syndrome
Ascites
- Most common complication of cirrhosis
- Clinically evident when > 1500 mL fluid has accumulated
Goals
-Mobilize fluid
-Decrease abdominal discomfort/pain
-Prevent complications
-Wt loss of 0.5-1 L per day
-Urine output should exceed fluid intake by 300-1000 ml/day
Ascites Therapy
Spironolactone 100 mg PLUS Furosemide 40 mg
-can increase every 3-5 days
-maintain 100:40 ratio
-max doses of 400 and 160
-furosemide added to minimize risk of hyperkalemia and enhance diuresis
Ascites, Alternative Diuretic Therapy
- Amiloride 10-40 mg or Eplerenone 25-50 mg
*when gynecomastia is intolerable, less effective - Metolazone 5-20 mg
- Triamterene 50-100 mg
- Torsemide 5-10 mg
- Bumetanide 0.5-2 mg
AEMTTB
Refractory Ascites
when unresponsive to sodium restriction and high-dose diuretic therapy
use Midodrine 7.5 mg po tid (2nd line therapy per AASLD guidelines)
ALSO: paracentesis (remove 1-10 L), albumin 6-8 g/1L IV given when > 5 L
Ascites, Non-Pharmacologic Therapy
-Protein 1-1.5 gm/kg/day
-Sodium < 2 and fluid (if Na < 120) restriction
-Avoid NSAIDs and ACEI/ARB
-DC alcohol
Ascites, Monitoring Parameters
-Body weight, abdominal girth
-Fluid intake
-Urine output
-Urina Na, K
-Hyponatremia, hyperkalemia
-Metabolic alkalosis
-Hypokalemia
-Gynecomastia
Spontaneous Bacterial Peritonitis (SBP)
Infection of the ascitic fluid
-gram-negative enteric bacilli (E.coli, Klebsiella)
Empiric therapy: Cefotaxime or Ceftriaxone IV then streamlined based upon cultures
Prophylaxis: pts with previous SBP episode
-Ciprofloxacin 500 or Rifaximin or Trime-Sulf
Esophageal Varices
Emphasis on PREVENTION of bleeding
-bleeding can be emergency/fatal
Goals
-Volume resuscitation, acute treatment of bleeding, prevention of recurrence
Esophageal Varices, AASLD Guidelines
-Vasoconstrictive Agent
AND
-Endoscopic band/variceal ligation
TIPS indicated for variceal bleeding refractory to pharmacologic and endoscopic therapy
Vasoactive Agents for Treatment of Acute Variceal Bleed
-Octreotide
*AE: diarrhea, abd pain, hyperglycemia, hypoglycemia, constipation
*2-5 days
-Vasopressin (+nitroglycerin) *24 hr
-SMT (not in US)
-Terlpressin *2-5 days
Esophageal Varices, Primary Prophylaxis
Indicated for pts with varices that have not bled and Child’s B or C
-Non selective beta blockers
carvedilol, EVL, nadolol, propranolol
PREVENTION of **recurrent varices* only
*Combination of either propranolol or nadolol + EVL is recommended
Hepatic Encephalopathy (HE)
Metabolic disorder of the CN
*altered mental status, flapping tremor (asterixis), sweet/musty breath
Drug induced CNS depression
-Sedatives, Tranquilizers, Narcotics
Goals
-Provide supportive care
-Identify and remove precipitating factors
-Reduce nitrogenous load from gastrointestinal tract
-Assess need for long-term therapy
