IP-5 Liver disease and cirrhosis review

Question 1

What is acute alcoholic hepatitis?

Answer 1

Occurs after decades of heavy EtOH consumption and rarely in people who binge drink that results in liver failure and death 40% of the time. AST/ALT > 2 X ULN. Use the DF or MELD score

Question 2

Signs and symptoms of cirrhosis

Answer 2

Jaundice, spider angiomata, nodular liver, splenomegaly, ascites, caput medusa, palmar erythema, gynecomastia, asterixis, anorexia, T2DM.

Question 3

How do we diagnose cirrhosis?

Answer 3

The only definitive way is by liver biopsy. Because this isn’t feasible, we use characteristic symptoms, ultrasound and laboratory values to diagnose cirrhosis.

Question 4

Which lab values are helpful in the diagnosis of cirrhosis or liver disease in general. What are the reference ranges?

Answer 4

Total protein (6-8.5), albumin (3.1-4.3), AST: (10-40 male, 9-25 female), ALT (10-55 male, 7-30 female), CBC and the inverted fishbone of LFTs (TP, Alb, AST/ALT, DBILI, TBILI, ALP)

Question 5

List the complications of cirrhosis

Answer 5

Portal hypertension (increased pressure within the portal venous system), esophageal varices, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy

Question 6

How can we tell if portal hypertension is present?

Answer 6

HVPG > 5 mmHg and is even more significant if HVPG > 10 mmHg OR through calculation of a SAAG score. (above 1.1 is diagnostic for portal hypertension)

Question 7

How do you calculate a SAAG score?

Answer 7

SAAG= serum albumin - ascites albumin (>1.1 = portal hypertension)

Question 8

What is esophageal varices and what factors determine the presence of varices

Answer 8

Blood back ups result in the formation of varices, which are alternate routes of blood flow. The higher the portal HTN, the higher the risk of varix formation (usually HVPG > 10)

Question 9

What is ascites?

Answer 9

An accumulation of fluid in the peritoneal cavity cause by lymph leakage from the capillaries into the peritoneal cavity.

Question 10

What is spontaneous bacterial peritonitis (SBP)?

Which microbes mostly present?

Answer 10

Infection in the ascitic fluid without a primary intra-abdominal source. The ascitic fluid allows overgrowth of bacteria such as E. coli and K. pneumoniae (most common)

Question 11

What is hepatic encephalopathy?

Answer 11

Disturbance in the CNS as a result of accumulation of nitrogenous substances present in bloodstream due to haptic insufficiency and liver failure. This substance alters neurotransmission leading to decreased cognition, confusion and behavioral changes.

Question 12

Treatment for acute alcoholic hepatitis

Answer 12

A DF score > or = 32 means you should initiate prednisolone 40mg daily x 28 days, then taper. Pentoxifylline and nutritional support are also recommended.

Question 13

Two options for primary prophylaxis of vatical bleeding

Answer 13

Surgical intervention or medication (Propranolol 20mg BID or nadolol 40mg once daily)

Question 14

Treatment for acute vatical bleeding

Answer 14

3 procedures: endoscopic procedures (band ligation, endoscopic injection sclerotherapy), pharmacotherapy, and interventional procedures (balloon tamponade).
7 day course of ABX therapy as prophylaxis against SBP.
Octreotide works by selectively constricting splanchnic vessels.

Question 15

Secondary prophylaxis of vatical bleeding

Answer 15

Most common regimen consists of non-selective B blocker plus serial endoscopic variceal ligation.

Question 16

Treatment for portal hypertension

Answer 16

Propranolol 20mg BID or nadolol 40mg daily

Question 17

Treatment for ascites

Answer 17

Aldosterone antagonist (spironolactone 100mg daily up to max 400mg daily). Furosemide (20mg BID up to max 80mg BID) is added to this regimen to minimize the risk of hyperkalemia and enhance diuresis to a target weight loss of 0.5kg/day

Question 18

Treatment for SBP

Answer 18

Most common empiric regiment is ceftriaxone 1gm Q 12 H x min of 5 days (14 days if confirmed with positive blood cultures)

Question 19

How to treat macrocytic anemia related to cirrhosis

Answer 19

BANANA bag (Folic acid, thiamine, and MultiV) in maintenance fluid

Question 20

Treatment for hepatic encephalopathy

Answer 20

Lactulose 20-30 grams PO Q 1 hour until BM, then 20-30 grams PO 3-4 X daily (titrated to 2-3 BM/day). Used to treat and prevent hepatic encephalopathy.
Rifaximin: Decrease the number of bacteria in the gut that produce the enzyme urease which prevents the conversion of urea to ammonia.
Metronidazole and neomycin are other options but not well studied.

Question 21

How does lactulose work?

Answer 21

Osmotic laxative that makes the patient excrete ammonia before it is able to be absorbed in the GI tract, thereby lowering systemic ammonia levels. Secondly, is that lactulose converts ammonia to ammonium which are not absorbed from the GI tract and thus excreted from the body.

Question 22

Monitoring parameters for patients with SPB

Answer 22

SCr and BUN should be monitored daily to asses for hepatorenal syndrome.

Question 23

Monitoring parameters for patients receiving B blocker for portal hypertension/varix formation

Answer 23

Patients taking non-selective B blockers should have their HR monitored (goal: 55-60 BPM or 25% reduction in resting HR)

Question 24

Monitoring parameters for patients with acute encephalopathy and hepatic encephalopathy

Answer 24

Restrict dietary protein intake to 10-20 g/day until acute episode resolves. Bowel movements and mental status should be monitored multiple times per day.