Hepatology Flashcards
AST levels are ___ in ___ liver dysfunction.
increased; acute
ALT levels are ___ in ___ liver dysfunction.
increased; acute
Alk phos levels are ___ in ___ liver dysfunction.
increased; acute
Bilirubin levels are ___ in ___ liver dysfunction.
increased; acute and chronic
Albumin levels are ___ in ___ liver dysfunction.
decreased; chronic
INR levels are ___ in ___ liver dysfunction.
increased; chronic
Platelet levels are ___ in ___ liver dysfunction.
decreased; chronic
Why does INR increase in chronic liver disease?
clotting factors are produced in the liver - therefore liver dysfunction leads to decreased clotting factors and increased INR
Why is thrombocytopenia associated with chronic liver disease?
Platelets are produced in the liver
What dose of acetaminophen can lead to DILI?
> /= 8 g
What molecule leads to DILI in those taking acetaminophen?
NAPQI
What are the signs/symptoms of acetaminophen DILI? (4)
abdominal pain; jaundice; N/V; diarrhea
What is used to treat acetaminophen DILI?
N-acetylcysteine (NAC)
How does NAC work?
provides cysteine for glutathione synthesis - glutathione breaks down NAPQI into inactive metabolites
How do you determine if NAC is indicated?
concentration of acetaminophen > 4 hours after ingestion
Dosing for NAC
140mg/kg loading dose followed by 70mg/kg Q4H for 17 doses
NAC monitoring parameters
liver enzymes; s/sx acute liver injury
What is cirrhosis?
irreversible fibrosis of the liver
What are the two main causes of cirrhosis?
EtOH abuse; Hepatitis
What are the signs/symptoms of cirrhosis?
fatigue; weight loss; itchy; jaundice; confusion; enlarged spleen and/or liver
Why does cirrhosis cause jaundice?
increased bilirubin
What is portal hypertension?
hepatic portal vein gradient > 5mmHg
What are the 2 complications of portal hypertension?
ascites; esophogeal varices
How does portal hypertension lead to ascites?
compensatory mechanisms lead to activation of RAAS which has stimulates several mechanisms that lead to ascites
Characteristics of decompensated cirrhosis (3)
variceal hemmorhage; ascites; hepatic encephalopathy
Surgical management of portal hypertension
TIPS
What is ascites?
fluid accumulation in the peritoneal space
Signs/Symptoms of ascites (4)
abdominal distention; abdominal pain; SOB; nausea
How does portal hypertension lead to ascites?
increased pressures drive fluid into peritoneal space
How does hyperalbuminurea lead to ascites?
increases risk of fluid going outside the vascular space
Non-pharmacologic ascites treatment
restrict sodium to < 2g daily
First-line treatment for ascites
100mg spironolactone + 40mg furosemide
Spironolactone ADRs (3)
AKI; increased potassium; gynecomastia
Furosemide ADRs (2)
AKI; decreased potassium
What do you switch a patient to if they experience gynecomastia with spironolactone?
eplerenone
Second-line treatment for ascites
paracentesis
What do you need to administer if you remove > 5L via paracentesis?
25% albumin
What is the dose of albumin after paracentesis?
6-8g per liter removed
Risk factors for variceal bleeding
larger varices; more severe cirrhosis; red wale signs; active alcohol use
Criteria for primary prohylaxis of variceal bleeding
varices > 5mm; red wale signs; decompensated cirrhosis
Treatment options for primary prophylaxis
non-selective beta blocker; EVL
Nadalol dosing for variceal bleeding prophylaxis
Initial: 20-40mg PO daily
Max: 80mg if ascites; 160mg if no ascites
Propranolol dosing for variceal bleeding prophylaxis
Initial: 20-40mg PO BID
Max: 160mg if ascites; 320mg if no ascites
Carvedilol dosing for variceal bleeding prophylaxis
Initial: 6.25mg PO daily
Max: 6.25mg PO BID
Non-selective beta blocker ADRs (4)
drowsiness; insomnia; bradycardia; hypotension
Non-selective beta blocker monitoring (3)
HR 55-60 bpm; SPB > 90 mmHg; s/sx of variceal hemorrhage
What should a patient receive immediately upon presentation of variceal bleeding?
blood transfusions; octreotide; antibiotic prophylaxis
What is the goal Hgb during a variceal bleed?
7-9 mg/dL
What is the octreotide dose for variceal bleeding?
50mcg IV bolus followed by 50mcg/hr for 2-5 days
Octreotide ADRs (4)
N/V; HTN; bradycardia; hyperglycemia
Antibiotic recommendation for variceal bleeding (with dosing)
Ceftriaxone 1g IV Q24H
When do you discontinue ceftriaxone?
7 days or after discontinuing octreotide
What is the goal time of EVL administration?
within 12 hours of presentation
What is a long-term solution for portal HTN and variceal bleeding?
TIPS procedure
What causes spontaneous bacterial peritonitis (SBP)?
bacterial translocation
Clinical presentation of SBP (4)
fever; abdominal pain/tenderness; leukocytosis; encephalopathy
How do you diagnose SBP? (2)
PNM leukocyte count > 250; positive ascitic fluid
How do you calculate the PNM leukocyte count?
WBC x Neutrophils
SBP treatment
Ceftriaxone 1g IV Q24H for 5 days
What are the two options for SBP prophylaxis?
Bactrim & ciprofloxacin
Non-pharm treatment for NAFLD/NASH
7-10% weight loss
Treatment for a diabetic patient with NASH
Pioglitazone 45mg PO daily
Treatment for a non-diabetic patient with NASH
Vitamin E 800 IU PO daily