Hepatology II Flashcards
Esophageal Varices (EV)
- Portal ___ causes hepatic/splanchnic ___ resulting in decreased perfusion
- Compensatory “varices” or small
offshoots form - Dilation of EV can occur and result in variceal bleeding, which can be severe
- hypertension
- vasodilation
Risk Factors for Variceal Bleeding
- Varices size (larger more likely to rupture)
- Cirrhosis severity (Child Pugh)
- Red color markings noted on endoscopy
- Active ___ use
alcohol
Variceal Bleeding Prophylaxis
Placebo RCTs of non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL) showed ↓ variceal and GI bleeding, but no ___ benefit
mortality
Primary Prophylaxis
___ OR ___ recommended monotherapy (not combination)
- NSBB: indicated in window of moderate disease
- Mechanism of action: splanchnic vasocontrictioon
NSBB, EVL
NSBBs
Dosing: adjust every 3 days until goals achieved
nadolol
- initial dosing: ___ - ___ mg PO D
- ___ mg (if ascites); ___ mg (if no ascites)
propranolol
- ___ - ___ mg PO BID
- ___ mg (if ascites); ___ mg (if no ascites)
carvedilol
- ___ mg PO daily (can increase to BID)
- ___ mg PO/day
Side effects:
- drowsiness or insomnia
- bradycardia
- hypotension
Monitoring:
- HR: goal __ - ___ bpm
- BP: SBP > ___ mmHg
- Signs/symptoms of VH
- 20-40, 80, 160
- 20-40, 160, 320
- 6.25, 12.5
- 55-60
- 90
EVL
Endoscopic procedure which bands off varices
- Used as ___ prevention and management of acute variceal bleed
- primary
Variceal Bleeding Clinical Presentation
Esophageal varices – asymptomatic
- Visualized via ___ (EGD)
Variceal bleeding
- ____
- Melena
- Fatigue
- Lightheaded/dizziness
- ___ tension
- endoscopy
- hematemesis
- hypotension
T or F: PPIs are recommended for variceal bleeds
FALSE
no evidence of support
Treatment of Variceal Bleeding
Immediately upon Presentation
- blood transfusions
- ___ (somatostatin analog, vasoconstrictor)
- ___ prophylaxis
- octreotide
- antibiotic
Octreotide
- Mechanism: inhibits release of vasodilatory peptides (i.e. glucagon) resulting in splanchnic ___ and ↓ blood flow
- Indications: ___ variceal bleed (not other types of GI bleeding)
- Meta-analysis showed ↓ mortality and transfusion in variceal bleeds
- Duration: recommended for 2-5 days (based on expert opinion)
- In practice, frequently stopped 24 hours after successful EVL
Side effects
- N/V
- ___ tension
- ___ cardia
- hyperglycemia
monitoring
- s/s
- BP
- HR
- BG
- vasoconstriction
- acute
- HTN
- bradycardia
EVL
- Gold standard for variceal bleeding cessation
- Goal is EVL within ___ hours upon presentation
- Bands could break and/or new varices could form so not ____ solution
- 12
- long term
Primary Antibiotic Prophylaxis
Indications: increased risk of infections with active variceal bleeding
Antibiotics recommended by guidelines:
- 3rd gen cephalosporin ( ___ )
- Side effects: ___
- Monitoring: signs/symptoms of infection, not ___ cleared so do NOT need to monitor ___
- Duration: until hemorrhage resolution (max __ days)
- ceftriaxone
- diarrhea
- renally, SCr
- 7
T or F: Vit K is recommended for high INR
FALSE
data does not show clinical benefit in patients with cirrhosis
Secondary Prophylaxis for Varices
- EVL: Every 1-4 weeks
- NSBBs: continue indefinitely (until decompensated)
- Dosing: adjust every __ days until goals achieved
- 3
EV Summary
- Evaluate for primary prophylaxis to prevent variceal bleeding
- For variceal bleeding, acutely manage with
transfusions, ___ , ___ primary
prophylaxis, and ___
After a variceal bleed, initiate secondary prophylaxis with ___ and/or ___
- octreotide, antibiotics, EVL
- NSBB, EVL
SBP Overview
Annual risk of SBP in patients with cirrhosis and
ascites is 10-30%
- Believed due to be bacterial ___ , in
which bacteria cross the intestinal barrier
translocation
SBP Clinical Presentation
- ___
- Abdominal pain/tenderness
- Leukocytosis
- ___
- Asymptomatic (in ~15% of patients)
- fever
- encephalopathy
Diagnosis
Therapeutic paracentesis
- Positive ascitic fluid bacterial culture
- Ascitic fluid with > ____ cells/mm3
polymorphonuclear ( ___ ) leukocytes
- PMNs = WBC from fluid x % neutrophils
- 250
- PMN
SBP Treatment
Antibiotics recommended by guidelines:
- 3rd gen cephalosporin ( ___ )
- side effects: ___
- Monitoring: signs/symptoms of infection (temp, WBC, cultures), not ___ cleared so do NOT need to monitor ___
Can tailor based on culture (not all will have a positive culture)
- Duration: __ - __ days^
- ceftriazone
- diarrhea
- renally, SCr
- 5-7
SBP Treatment
___ has been shown to decrease mortality and AKI/HRS in patients with SBP
- Day 1: ___ g/kg x1 (within 6 hours of SBP diagnosis)
- Day 3: ___ g/kg x1
albumin
1.5
1
SBP Secondary Prophylaxis
Recurrence of SBP within 1 year is ___ %
- Recommended to initiate SBP secondary prophylaxis with antibiotics and avoid ___ (which increase risk of SBP)
- 2 antibiotics: ___ and ___
- duration: ___
- 70%
- PPIs
- Bactrim, ciprofloxacin
- indefinite
SBP Summary
Evaluate need for antibiotics for treatment
- Longer SBP treatment duration is not better
Initiate secondary SBP prophylaxis with ___ or ___
- Monitor for side effects and future SBP
- Bactrim, ciprofloxacin
Dosing in Liver Insufficiency
No endogenous marker for hepatic clearance that can be used to guide drug dosing
Things to consider
- Extent of hepatic metabolism/activation of the medication
- Decreased metabolism and decreased activation with cirrhosis
- Severity of liver disease (i.e. Child-Pugh)
- Highly protein bound drugs → ↑ ___ drug concentration, but not total drug concentration
- Consider avoiding/limiting hepatotoxic medications - However, not all may worsen (i.e. ___ in NAFLD/NASH)
- Monitor adverse effects of medications as well as hepatic enzymes and liver
function markers
- free
- statins
