Hepatology Flashcards
What is the function of the liver?
- Makes Bile [Digests food]
- Metabolism of Drugs/Food/Toxins [activates prodrugs]
- Protien Synthesis [albumin and coag]
- Storage of vitamins
What are some of the Objective markers for Liver failure?
- Aspartate Transminase [AST]: 0-50 IU/L
- Alanine Transaminase [ALT]: 0-50 IU/L
- Alkaline Phosphatase [Alk Phos]: 30-120 IU/L
- Bilrubin: 0-1.4 mg/dL
- Albumin: 3.6-5.0g/dL
- INR: 0.9-1.1
- Thrombocyopenia: 150-450k
What is important to know about the Objective Markers in Liver Failure?
- AST, ALT, Alk phos = acute liver injury
- Decrease albumin, Increase INR, and/or Increase Bilirubin = Chronic Liver Disease
What is the estimated incidence of Drug-Induced Liver Injury?
- 14-19 cases per 100,000 people [0.014%]
- Have Jaundice
What are the classifications/mechanisms of liver injury/
- Direct [Acetaminophen]
- Idosyncratic [Beta-lactams, Fluoroquinolones, macrolides]
- Indirect [metabolic abnormalities causing non-alcoholic fatty liver disease]
What are the medications that are highest risk of causing Drug-Induced Liver Injury?
- ACETAMINOPHEN
- Anti-fectives [Isoniazid, Beta-Lactams, Fluoroquinolone, Macrolide]
What do you do with the medication if you suspect DILI?
- HOLD the agent
What is important to know about Acetaminophen DILI?
- High dose [>8g] causes toxic levels of N-Acetyl-p-benzoquinoe imine (NAPQI) = hepatotoxicity
- S/Sx: Abdominal pain, jaundice, N/V/D -^
- Can be reversed
What is the way that we reverse Acetaminophen DILI?
- N-Acetylcysteine [NAC] +/- activeted charcoal
What is the MOA for N-Acetylcysteine (NAC)?
- Binds to NAPQI, mimics Glutathione helping make NAPQI non-toxic metabolite [decreases hepatotoxic effects}
What way do we know how to use N-Acetylcysteine [NAC]?
- Conc. of Acetaminophen [>4hr after ingestion] and time of ingestion
- ORAL & IV
- USED RUMACK-MATTHEW NOMOGRAM
Describe how the Rumack-Matthew Nonogram is used?
- The “white” side = NO NAC; the “grey” side = NEED NAC
What is the definition of Cirrhosis?
- Severe, chronic, IRREVERSIBLE fibrosis of the liver
- INCREASED morbidity and mortality`
What are some of the causative factors for Cirrhosis?
- ALCOHOL [#1 in US]
- Viral Hepatitis
- Metabolic/Cholestatic Liver Disease
- Drug [Amiodarone, Methotraxate]
What are the two drugs that could cause Cirrhosis?
- Chronic use of Aminodarone or Methotrxate
What are the signs and symptoms of Cirrhosis?
- Fatigue, Weight Loss, Ascites, Jaundice, Hepatomegaly, Encephalopathy
What is the way that we assessing severity of Cirrhosis?
- Child-Pugh & Model for End-stage Liver Diease [MELD]
What is important to know about Child-Pugh score?
- Predicts mortality in Cirrhosis
- Class B: 7-9 = moderate severity
- Class C: 10-15 = severe severity
What is important to know about Model for End-stage Liver Disease?
- Predicts 3 month-mortality risk and used in transplant prioritization
- <9 = 1.9% risk to >40 = 71% risk
What is Ascites in liver disease?
- Fluid accumulation in the peritoneal space
- S/Sx: Distension, Pain, SOB, Nausea
What is the pathophysiology of Ascites?
Increased pressure within the portal hypertension that moves fluids into the peritoneal space
What is the way that we manage Ascites in liver disease?
- Non-pharm: restrict Sodium
- 1st line: Spiro & Furo
- 2nd line: Paracetesis
What is one class of drugs that should not be used in patients with Cirrhosis?
- NSAIDS - could increase fluid retention & vasodilatoin
What is important to know about the 1st line treatment of Ascites?
- Spiro 100 : Furo 40 once dialy
- COMBO is better than MONO [SPIRO is better than Furo]
What are some of the side effects and monitoring for Diuretics for Ascites?
- Spiro [Increased Potassium, Gynecomastia]
- Furo [Decreased Potassium]
- MONITOR: S/Sx of ascites, Scr, K+
What is Paracentesis?
- SECOND LINE for chronic; pulls fluids out of parental space
What happens when you remove >5L of fluids via Paracentesis?
- USED ALBUMIN [6-8g albumin per L]
- Decreases morbidity and mortality
What is Esophageal Varices?
- Portal Hypertension were blood is blocked by a scar or clot and goes to another vein where it cant handle it and ruptures it; causing bleeds
What are some of the risk factors for Variceal Bleeding?
- Size [Larger = Rupture]
- Child-Pugh
- Red Marking via Endoscopy
- ALCOHOL
What is the Prophylaxis treatment for Variceal Bleeding?
- Non-Selective Beta-Blockers [NSBBs] OR Endoscopic Variceal Ligation [EVL] –> decrease variceal and GI bleeds
- NOT COMBO
What is the MOA to know about the NSBBs?
- b2 = vasoconstriction & b1 = decreased HR & CO
- Helps manage portal hypertension
What are the 3 NSBBs that are used in Variceal Bleeding?
- Nadolol, Propranolol, Carvedilol
What are the side effects and monitoring parameters for the NSBBs?
- Drowsiness, Bradycardia, HYPOtension
- HR: 55-60 BPM
- BP: SBP > 90mmHg [dont want HYPOtension]
What is Endoscopic Variceal Ligation [EVL]?
- Endoscopic procedure which BANDS off varices; keeping it from rupturing
- PRIMARY preventing and acute management
What are some of the clinical presentations for Variceal Bleeding?
- ENDOSCOPY [see it]
- Hematemesis [throw up blood]
- Melena [bloody stool]
- Fatigue, dizziness, HYPOtension
What is the treatment for Variceal Bleeding?
- IMMEDIATELY: Blood transfusion, Octrotide, Antibiotic
- Sugrical: EVL - gold standard of bleeding
- After EVL: Secondary Prophylaxis
Wheat is NOT recommended for Variceal Bleeds?
- Proton Pump Inhibitors [PPIs]: no data to support
What is the MOA for Octrotide in Variceal bleeds?
- Inhibits release of vasodilatory peptide causing vasoconstriction and decreased blood flow
- For the acute variceal bleeds
What are some of the side effects for Octrotide?
- N/V
- HYPERtesion: monitor BP
- Bradycardia: monitor HR
- HYPERglycemia: monitor BG
What is the gold standard in variceal bleeding cessation?
- EVL
- Bands might break so not really long term
What is the primary antibiotic prophylaxis that is used for Variceal Bleeding?
- Ceftriaxone - when increased risk of infections with active bleeding for 7 DAYS
- DIARRHEA
- NOT RENALLY CLEARED
What is the secondary prophylaxis that is used for Variceal Bleeding?
- EVL: every month
- NSBB: Nadolol, Propranolol [same SE and Monitoring]
What is the proposed underlying pathophysiology for Hepatic Encephalopathy?-
- INCREASED ammonia
- disorientation [A/Ox1]
For acute management, what are the recommended therapies? What are preferred vs second line?
- Lactulose 25ml BID
- Rifaximin [after failure second occurance]
When is HE prophylaxis recommended?
- After any occurrence of HE
- Prophylaxis with Lactulose
What should we monitor within HE?
- Bowel Movements
- Mental Status
- NOT AMMONIA AGAIN
What is the clinical presentation of Spontaneious Bacterial Peritonitis [SBP]?
- Bacteria crossing the intestinal barrier
- Fever, Abdominal Pain, Leukocytosis [Increase WBC], Encephalopathy
In what way do we diagnosis SBP?
- Theraputic Paracentesis [Remove little fluids]
- [+] Culture & PMN > 250 cells/mm^3
- PMN = WBC * % neutrophils
What is the treatment for SBP?
- Ceftriaxone for 5-7days; DIARRHEA [C. Diff]; NOT RENALLY CLEARED
- Albumin: decreases mortality [Days 1&3]
What is used for Secondary prophylaxis for SBP?
- SMZ-TMP [Bactrim] OR Ciprofloxacin
- INDEFINTIE treatment
Cirrhosis Summary: When to treat for Ascites?
- When ascites is PRESENT
Cirrhosis Summary: What is the first line for Ascites?
- Spironolactone 100 + Furosemide 40
Cirrhosis Summary: When to use prophylaxis for Ascites?
- Primary: N/A
- Secondary: Trying to prevent Paracentesis
Cirrhosis Summary: What should you monitor for some with Ascites?
- S/Sx of Ascites [distention, pain, SOB, nausea], SCr, K+
Cirrhosis Summary: When to treat someone with EV?
- Active Variceal Hemorrahge [current bleeding]
Cirrhosis Summary: What is the first line therapy for EV?
- +/- Blood Transfusion + Octreotide + Ceftriaxone + EVL
Cirrhosis Summary: When to use prophylaxis for EV?
- Primary: FYI
- Secondary: After Hemorrhage, Indefinite as long as BP tolerates
Cirrhosis Summary: What is the first line Prophylaxis for EV?
- NSBBs OR EVL
Cirrhosis Summary: What shoudl you monitor for someone with EV?
- S/Sx of Bleeding, HR [goal 55-60 BPM], BP [Goal > 90 SBP]
Cirrhosis Summary: When to treat for SBP?
- culture OR PMN > 250 cells/mm^3
Cirrhosis Summary: What is the first line threapy for SBP?
- Ceftriaxone [or 3rd gen ceph] + albumin days 1/3
Cirrhosis Summary: When to use prophylaxis for SBP?
- Primary: Active Hemorrhage
- Secondary: After SBP; indefinite
Cirrhosis Summary: What is the first line prophylaxis for SBP?
- Bactrim [or Cipro]
Cirrhosis Summary: What should you monitor for in SBP?
- S/Sx of infection, SCr
Cirrhosis Summary: When to treat for HE?
- Encephalopathy +/- Increased Ammonia [rule out other causes]
Cirrhosis Summary: What is the first line therapy for HE?
- Lactulose [target > 3 Bowel Movements/day]
Cirrhosis Summary: When to use Prophylaxis in HE?
- Primary: N/A
- Secondary: after any occurrence of HE
Cirrhosis Summary: What is the first line prophylaxis for HE?
- Lactulose
Cirrhosis Summary: What should you monitor for in HE?
- Bowel Movements [>3/day], Mental Status, NOT AMMONIA AGAIN
