Exam 3 Flashcards
Complications of cirrohosis
ascites portal HTN variceal bleeding SBP HE HRS
SBP stands for
spontaneous bacterial peritonitis
HE stands for
Hepatic encephalopathy
HRS stands for
Hepatorenal syndrome
Scoring for transplant considerations
MELD
Scoring for dosage adjustments
Child Pugh
Most common complication of cirrohosis
ascites
Ascites physical exam
full tense bulging abdomen
Diagnosis for portal HTN
SAAG ≥ 1.1
Ascites treatment
Na2+ restriction 2g/day
Spironolactone 100
Furosemide 40
Large volume paracentesis
Ascites and systolic BP under 90 treatment
Midodrine 7.5 TID
AEs of large volume paracentesis
drop BP and increase SCr
How to treat increasing SCr in large volume paracentesis
More than 5L give IV albumin 25% 8g IV for every liter of fluid removed
TIPS stands for
Transjugular intrahepatic portosystemic shunt
What is TIPS in simple terms
A stent that connects the portal and hepatic vein to avoid the liver to relieve some of the pressure
TIPS used to treat
refractory ascites
refractory variceal bleeding
AEs of TIPS
Hepatic encephalopathy
Why do we treat portal HTN
to prevent variceal bleeding from developing
How to diagnosis portal HTN
EGD and SAAG ≥ 1.1
Treatment for portal HTN
Non selective beta blockers (propanolol, nadolol, carvedilol)
Holding parameters for non selective beta blockers for portal HTN
Systolic < 90 diastolic < 60 HR < 60 HRS refractory ascites SBP
In cirrhosis you can have normal LFTs
true or false
True
How can cirrhotics have normal LFTs
they killed all their hepatocytes already
Cirrhosis signs
low albumin
high bili
low platelets
high PT INR
Acute variceal bleeding caused by
portal HTN
Treatment for acute variceal bleeding
Supportive care IV octreotide EVL SBP prophylaxis once stabilized - non selective beta blockers
Supportive treatment for acute variceal bleeding
IV fluids
PRBC (Hg=8)
oxygen
Octreotide dose in actue variceal bleeding
50 mcg bolus then infusion
SBP prophylaxis treatment
7 days IV Ceftriaxone (3rd gen)
or Cipro if allergic
SBP caused by
bacterial infection of ascitic fluid enteric gram -
Diagnosis of SBP
Absolute polymorphonnucleated leukocyte ≥ 250
+ bacterial culture (will still treat if negative)
SBP active infection treatment
Ceftriaxone or Cefotaxime (Cipro if allergy)
IV for 5 days
possibly IV albumin 25%
Why give albumin in SBP active infection
SCr > 1
BUN > 30
Bili > 4
any one of these 3
Albumin dose in SBP active if needed
IV albumin 25%
1.5 g/kg on day 1
1 g/kg on day 3
When can you give SBP prophylaxis
variceal bleeding (3rd gen 7 days)
or indefinite for patients with history of SBP
or indefinite for patients ascitic protein
SAAG
albumin in ascitic fluid to serum albumin gradient
Indefinite SBP prophylaxis treatment drugs
Cipro 250-500 QD
Bactrim DS 1 tablet QD
Hepatic encephalopathy causes
ammonia toxin buildup for decreased hepatic function and portal systemic shunting
Treatment for HE
Lactulose + Rifaximin
Lactulose acute HE dose
25 ml PO q1-2 until 2 loose stools or
300ml retention enema q6-12
Lactulose prevention HE dose
15-60ml PO q6-12hrs to 2-3 soft BM a day
Rifaximin can be given alone to treat HE
True or false
False
Rifaximin acute HE dose
400mg PO q8hrs
Rifaximin maintenance
550mg POO BID
HRS is
splanchnic vasodilation secondary to portal HTN
HRS mortality rate
high
2-4 week survival rate
When to give streamline treatment in SBP active
after 48-72 hrs
switch just to target
How to diagnose HRS
cirrhosis with ascites
SCr ≥ 0.3 in 48 hrs or ≥ 50% in baseline in 7 days
No improvement in SCr 2 days after diuretic cessation and IV albumin = HRS
How to presenting for variceal bleeding
throwing up blood
tachy
low Hg
HRS treatment
liver transplant
IV NE and IV albumin 1 g/kg/day
HE signs
falling asleep
not responsive during exam
asterixis
High ammonia = severity HE
true or false
False
higher ammonia means HE but how high doesn’t mean increased severity
HRS treatment if no decrease of SCr in 4 days what should we do
d/c therapy and get liver transplant
PKPD changes in cirrhosis
Decrease liver blood flow loss of hepatocyte function Decrease albumin production Decrease renal function when SCr increasd increased therapeutic response
Decrease liver blood flow what should we do
impacts high first pass drugs
may need to decrease dose
Loss of hepatocyte function
what should we do
effect phase I (CYP) more so switch to drug metabolized by phase II
Decreased albumin
what should we do
decrease dose for heavily protein bound drugs
Increased therapeutic response
what should we do
BBB more permeabile
decrease dose
