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Clin Therapeutics II (Spring 2018) > Exam 1: Cirrhosis > Flashcards

Exam 1: Cirrhosis Flashcards

1
Q

What is a detectable and pathological collection of fluid in the peritoneal cavity?

A

Ascites

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2
Q

Ascites most common complication of what?

A

Cirrhosis

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3
Q

Common Causes of ascites?

A

Chronic liver dz, portal HTN, hypo albuminuria, cardiac, TB, lymphoma

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4
Q

First indication of cirrhosis on physical exam?

A

Flank dullness

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5
Q

Symptomatic clues for ascites

A

Chronic liver disease - Palmar erythema, spider nevi, jaundice

Portal HTN – splenomegaly and large collateral veins

Cardiac – engorged jugular veins

Lymph Nodes – TB or Lymphoma

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6
Q

What is involved with the work up for ascites?

A 
LABS: CBC, CMP, LFTS, Urea
Abdominal US
Dx Paracentesis
Ascitic Fluid Analysis
Calculate SAAG
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7
Q

How many grades of ascites?

A

3

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8
Q

Grade 1 ascites detectable only by what?

A

Ultrasound

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9
Q

Grade 2 ascites in abdomen looks like?

A

Moderate symmetric enlargement of abdomen

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10
Q

Grade 3 ascites looks like what in abdomen? What additional thing does it have?

A

Marked abdominal enlargement. Transmitted thrill.

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11
Q

DX for ascites?

A

Paracentesis

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12
Q

What does SAAG stand for in ascites?

A

Serum albumin ascites gradient

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13
Q

How is SAAG calculated?

A

Serum albumin - ascites albumin

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14
Q

SAAG >1.1 result indicates what? What does it suggest?

A

> 1.1 indicates portal HTN. Suggests non-peritoneal cause of ascites.

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15
Q

Tx for Grade 1 ascites?

A

Salt restriction (dont need to know numbers)

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16
Q

Tx for Grade 2 ascites?

A

Salt restriction + diuretics (K+ sparring Spironolacton)

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17
Q

When would you consider fluid restriction in ascites?

A

ONLY considered in those with dilutional hyponatremia
Na < 125

Normal = 135-145

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18
Q

What type of diuretics to use for ascites?

A

Aldosterone-antagonist (ex: Spironolactone)

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19
Q

Why are aldosterone antagonists preferred over loops?

A

Renal sodium retention in pots with cirrhosis is d/t increased Prox and diet tubular Na reabsorption and not decrease in filtered Na

Also these pt have increased serum aldosterone d/t decreased intravascular volume and decreased renal perfusion—> RAAS
Decreased excretion d/t hepatic impairment —> decreased metabolism

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20
Q

What to add if hyperkalemic in ascites?

A

Furosemide

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21
Q

When to d/c Furosemide in ascites?

A

Na <120, renal failure, encephalopathy, severe muscle cramps

Severe hypoK < 3

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22
Q

Goal of weight loss if + edema in ascites?

A

1kg/d max

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23
Q

Goal of weight loss if no edema in ascites?

A

0.5kg/d max

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24
Q

Tx for Grade 3 ascites?

A

Large volume paracentesis + salt restrict + diuretics

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25
Q

Volume to drain from paracentesis in ascites?

A

5L

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26
Q

What to add when doing paracentesis in ascites to prevent circulatory dysfunction?

A

Albumin 6-8g/L

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27
Q

Tx is Grade 3 ascites and having to do paracentesis 3+ per month and not a liver transplant candidate?

A

TIPS

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28
Q

What does TIPS do in ascites?

A

Shunt between high pressure portal vein to low pressure hepatic vein

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29
Q

When is TIPS Contraindicated

A

If already Hepatic Encephalopathic, will accumulate more ammonia

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30
Q

What is considered portal vein HTN?

A

Pressure > 10-12mmHg

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31
Q

What should you consider for tx if HRS with ascites

A

IV albumin

With octreotide and midodrine

32
Q

What is Brad’s favorite ice cream at JP Licks?

A

Chocolate chip cookie dough

33
Q

What K+ to stop Lasix/Furosemide in ascites?

A

If K<3

34
Q

Why is Spironolatcone given to ascites patients?

A

They have higher serum aldosterone and impaired aldosterone excretion

35
Q

What K+ to stop Spironolactone in ascites?

A

If K>6

36
Q

What do to with diuretics if hepatic encephalopathy occurs? Why?

A

Stop diuretics! Hypovolemia makes it worse.

36
Q

Some common complications of Ascites?

A 
Umbilical hernia
Hydro Thorax—Pleural effusion R>L
SBP from fluid
Hepatic Renal syndrome
Hepatic encephalopathy
37
Q

What infx has 50% risk with ascites?

A

Spontaneous Bacterial Peritonitis

38
Q

2 MC bacteria in Spontaneous Bacterial Peritonitis?

A
  1. Gram - E Coli

2. Gram + Strep

39
Q

Range of symptoms in Spontaneous Bacterial Peritonitis?

A

ASx to septic

40
Q

ANC of ascitic fluid in Spontaneous Bacterial Peritonitis?

A

ANC >250

41
Q

What is ANC is <250 in Spontaneous Bacterial Peritonitis?

A

Might be early SBP

42
Q

TX of Spontaneous Bacterial Peritonitis?

A

IV Ceftriaxone 1g q12h 5-10d (5 days)
(third gen cephalosporin)

Alternates: Augmenting (Amox/clav) and FQs, but most on FQs anyway for ppx

43
Q

Repeat paracentesis in Spontaneous Bacterial Peritonitis until when?

A

ANC <250 and sterile cultures

44
Q

What fails in Hepatorenal Syndrome?

A

Renal failure in advanced liver disease

45
Q

Cause of renal failure in Hepatorenal Syndrome?

A

No discernable cause

46
Q

What do you need to r/o before diagnosing HRS?

A

Hypovolemia
Shock
Parenchyma renal dz - if proteinuria or micro-hematuria
Nephrotoxins

47
Q

Hepatorenal Syndrome (HRS) 1 timeframe?

A

Over 2 weeks.

47
Q

What are the criteria for diagnosing HRS in cirrhosis? (HINT: 6)

A
  1. Cirrhosis with ascites
  2. SCr > 1.5mg/dL
  3. Absence of shock
  4. Absence of hypovolemia (no sustained improvement of renal fx following at least 2 days of diuretic withdrawal and volume expansion with albumin at 1g/kg/day)
  5. NO current or recent tx with nephrotoxic drugs
  6. Absence of parenchymal renal dz (no proteinuria >0.5g/day or microhematuria >50rbc, and normal renal US)
48
Q

HRS 1 has 100% increase in what?

A

Cr

49
Q

HRS 2 compared to HRS 1?

A

Stable and less progressive impairment

50
Q

What to make sure about nephrotoxic drugs in Hepatorenal Syndrome?

A

No current or recent

51
Q

How to tx Hepatorenal Syndrome?

A

Stop diuretics, vasopressin analogues, renal replacement therapy (dialysis), Liver transplant

52
Q

When should you stop spironolactone in HRS treatment?

A

If K > 6, can cause hyperK arrhythmia

53
Q

Ammonia build up in brain d/t which disease?

A

Hepatic Encephalopathy

54
Q

Hepatic Encephalopathy is a ________ presentation of liver dz

A

Neuropsychiatric

55
Q

What percent of cirrhosis patients have Hepatic Encephalopathy?

A

70%

56
Q

Signs of Hepatic Encephalopathy? (changes, impairments)

A

Personality changes, intellectual impairments, depressed level of consciousness

57
Q

Patho genesis of HE (HINT: which cells of brain involved)

A

Astrocytes (form BBB), are altered in liver failure, and may produce brain edema, ICP and possibly herniation

57
Q

How are enterocytes involved in progression of HE?

A

They convert GLUTAMINE —> GLUTAMATE + AMMONIA

58
Q

Precipitating factors of HE (HINT: refer to whole lecture)

A

+Constipation: need to clean out ammonia producing gut flora
+Infections: produce septic encephalopathy and can mimic HE, or inc N wastes
+GIB: protein in blood—>increase in N wastes—> increase in ammonia
+shunts: decreased liver detox
+Renal failure: decreased clearance of ammonia, urea and other N wastes
+Meds: Many rx act upon CNS (Benzos, antidepressants/psychotics)
+Diuretcs: decreased K levels and alkalosis —> conversion of NH4+ to NH3)

58
Q

Chemistry lesson: What is NH3 and what is NH4+?

A

Ammonia = NH3

Ammonium = NH4+

59
Q

HypoKalemia leads to acidosis or alkalosis. Why is this important?

A

HypoK can lead to alkalosis which will facilitate conversion of ammonium to ammonia

60
Q

What to rule out in Hepatic Encephalopathy? How?

A

CT to rule out head bleed

EEG to r/o seizures

61
Q

Most important dx in Hepatic Encephalopathy?

A

Ammonia level!

62
Q

Goal of Hepatic Encephalopathy treatment?

A

Lower nitrogen in GI tract

64
Q

Purgative does what in Hepatic Encephalopathy?

A

Poop out nitrogen before absorbed

66
Q

How does Lactulose work in Hepatic Encephalopathy?

A

Works in colon to convert ammonia to ammonium which is poorly absorbed

67
Q

Dosing for lactulose, and what happens if dosed too heavily

A

Dose 20-60mg 3x daily titrate to achieve 2-4 soft stools/day w/o diarrhea, but can also go through NGT or enema in hospital

Warn pt not to overdose as can cause hypovolemia and can worsening encephalopathy

68
Q

What 3 abx indicated for Hepatic Encephalopathy?

A

Neomycin
Flagyl
ORAL vanco
Rifaximin

69
Q

Neomycin, Flagyl, and PO Vanco for Hepatic Encephalopathy?

A

Decrease ammonia-generating bacteria

71
Q

Which abx is second line agent after failure of lactulose?

What is a risk of this abx

A

Neomycin
Is an aminoglycoside which can cause renal failure, thus further stasis of ammonia, fluid/electrolyte imbalances and worsening HE

72
Q

Which abx at 400mg TID is as effective as lactulose?

A

Rifaxamin

73
Q

2 other tx options in Hepatic Encephalopathy?

A

Probiotics and Fermented fibers

75
Q

How do probiotics work for HE?

A

Reduces intestinal ammonia production by enterocyte glutiminase and reduce bacterial translocation, modulate proinflammatory and modulate gut permeability

Form an acidic state (drives ammonia to ammonium)

Works as laxative

Clin Therapeutics II (Spring 2018) (11 decks)

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