Hepatic Disease Flashcards
Cirrhosis
What are the causes of cirrhosis?
- alcohol use
- virus (hepatitis B and C)
- non alcoholic steatohepatitis (NASH)
- immunologic (Wilson’s disease, autoimmune)
- drugs
Cirrhosis
What is the use of Child-Turcotte-Pugh?
defines severity, predicts survival, helps with drug dosing
Cirrhosis
What are the Child-Turcotte-Pugh classes?
- A (mild)
- B (moderate)= significant functional compromise
- C (severe)= decompensated disease
Cirrhosis
What are the complications associated with cirrhosis?
- ascites
- varices
- hepatic encephalopathy
- hepatorenal syndrome
Cirrhosis
What is ascites?
developement of fluid retention in the peritoneal cavity due to activation of the renin-angiotensin-aldosterone system= sodium and water retention, renal vasoconstriction, hyperdynamic circulation
Cirrhosis
How is ascites diagnosed?
serum-ascites albumin gradient (SAAG), 1.1 g/dL+ is indicative of portal hypertension
Cirrhosis
What is the treatment for acute episode of tense ascites?
paracentesis +/- albumin +/- midodrine
Cirrhosis
What is the maintenance therapy for ascites?
- alcohol abstinence
- sodium restriction
- diuretics
Cirrhosis
When is albumin indicated for patients with ascites?
large volume paracentesis with 5+ L removed from the patient
Cirrhosis
How is albumin dosed in patients with ascites?
6-8 gram/L of fluid removed
Cirrhosis
Why is albumin given after paracentesis in patients with ascites?
- reduced mortality
- large volume removed may cause post-paracentesis circulatory dysfunction (PPCD): hypotension, shock, acute kidney injury, hepatorenal syndrome, and recurrent ascites
- helps maintain intravascular volume
Cirrhosis
What diuretics are preferred in patients with ascites?
furosemide (loop) and spironolactone (aldosterone antagonist), maintaining 40:100 ratio (furosemide:spironolactone)
Cirrhosis
What are the adverse effects of spironolactone?
- gynecomastia
- hyperkalemia
- dehydration
- hypotension
Cirrhosis
What are the adverse effects of furosemide?
- acute kidney injury
- electrolyte disturbances
- dehydration
- hypotension
Cirrhosis
What are the monitoring parameters while taking diuretics?
- SCr
- Na, K
- Weight
Cirrhosis
When would diuretics be held?
- sodium < 120 mEq/L
- SCr > 2 mg/dL
- K > 6 mEq/L
- encephalopathy
Cirrhosis
What is the indication of Midodrine use?
- refractory ascites
- hepatorenal syndrome
Cirrhosis
What are the adverse effects of Midodrine?
- parasthesias
- piloerection and pruritis
- dysuria and urinary retention
Cirrhosis
What medications should be avoid with ascites?
- meds that increase fluid retention= NSAIDs and thiazolidinediones (TZDs)
- maintain higher BP so use vasodilators with caution (ACEI, ARB, hydralazine) and beta blockers should also be used with caution
- avoid nephrotoxins
Cirrhosis
What is apontaneous bacterial peritonitis (SBP)?
bacterial infection of the ascitic fluid caused by the translocation of intestinal normal flora into ascitic fluid
Cirrhosis
What are the common causitive organisms of spontaneous bacterial peritonitis (SBP)?
- E. coli
- Klebsiella pneumoniae
- Streptococcus pneumoniae
- possibly S. aureus and enterococcus
Cirrhosis
How is spontaneous bacterial peritonitis (SBP) diagnosed?
paracentesis for ascitic fluid analysis and signs and symptoms of infection (fever, abdominal pain, tenderness)
Cirrhosis
When would primary prophylaxis be indicated for spontaneous bacterial peritonitis (SBP)?
ascitic fluid protein < 1.5 g/dL and one of the following:
- impaired renal function (SCr > 1.2 or BUN > 25)
- serum Na < 130
- liver failure (CTP > 9 and bilirubin > 3)
Cirrhosis
What drugs can be used for primary prophylaxis of spontaneous bacterial peritonitis (SBP)?
- ciprofloxacin
- levofloxacin
- trimethoprim-sulfamethoxazole
Cirrhosis
What is the preferred treatment for spontaneous bacterial peritonitis (SBP)?
3rd gen cephalosporin (cefotaxime and ceftriaxone) and albumin
Cirrhosis
What is the duration of treatment for spontaneous bacterial peritonitis (SBP)?
5 days
Cirrhosis
When would albumin be indicted for spontaneous bacterial peritonitis (SBP)?
signs of renal impairment or severe hepatic dysfunction- one of the following: SCr > 1, BUN > 30, total bilirubin > 4
Cirrhosis
What is the primary prophylaxis for varices?
non-selective beta blockers (carvediol, propranolol, nadolol)
need to have evidence of varices to start treatment
Cirrhosis
What is used to manage an active bleed due to varices?
- octreotide
- antibiotics
- HOLD beta blocker
Cirrhosis
How do nonselective beta blockers reduce the portal pressure in varices?
- decreased cardiac output
- decreased splanchnic blood flow
- decreased intrahepatic vascular resistance through vasodilation
Cirrhosis
What are the adverse effects of non-selective beta blockers?
- bradycardia/hypotension
- fatigue
- lightheadedness
- shortness of breath
Cirrhosis
What is the use of Octreotide in varices?
reduction in portal pressure
Cirrhosis
What are the adverse effects of octreotide?
- GI (diarrhea, flatulence, abdominal pain)
- bradycardia
- hypertension
Cirrhosis
What are the antibiotics used in varices?
- ciprofloxacin
- ceftriaxone
- ampicillin/sulbactam
duration: stable for discharge or 7 days
Cirrhosis
What is the clinical presentation of hepatic encephalopathy?
- early= attention, memory, psychomotor speed
- as progresses= personality changes, sleep-wake disturbances, disorientation, motor changes
serum ammonia is not indicative of symptoms
Cirrhosis
What is the treatment of acute episode of hepatic encephalopathy?
- treat predisposing factors (constipation, infection, diuretic overuse, GIB, electrolyte abnormalities)
- nutrition (protein management)
- lactulose
- +/- rifaximin
- +/- other antibiotics
Cirrhosis
What is the mechanism of action of lactulose?
encourages ammonium to be excreted in the feces
Cirrhosis
How is lactulose dosed for hepatic encephalopathy?
given hourly until bowel movement, then Q6-8H until 2-3 bowel movements a day
Cirrhosis
What are the adverse effects of lactulose?
- diarrhea
- flatulence
- abdominal pain/cramping
- unpleasant taste
Cirrhosis
What is the use of rifaximin in hepatic encephalopathy?
non-absorbed antibiotics that inhibits urease producing bacteria within the GI tract
Cirrhosis
What are the adverse effects of rifaximin?
- GI= flatulence, abdominal pain
- headache
- urtcarial skin reactions (rare)
Cirrhosis
What is the management of hepatorenal syndrome?
- discontinue diuretics and treat other potential causes of AKI
- albumin 25%
- terlipressin until SCr returns to baseline (up to 14 days)
Cirrhosis
What is the mechanism of action of terlipressin in hepatorenal syndrome?
vasopressin analogue, systemic vasoconstriction
Cirrhosis
What is the black box warning of terlipressin?
serious or fatal respiratory failure, monitor O2 status and do not initiate if O2 < 90%
Cirrhosis
What are the adverse effects of terlipressin?
- ischemic events (avoid in severe cardiovascular disease)
- GI= abdominal pain, diarrhea
- dyspnea
- hyponatremia
