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cdm 2 exam 3 > Lecture 2 - ESLD Complications > Flashcards

Lecture 2 - ESLD Complications Flashcards

1
Q

Portal Hypertension due to…

A

Fibrosis in liver interfering with normal blood flow

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2
Q

What is Portal Hypertension

A

When portal blood flow is impeded and portal pressure exceeds 12 mmHg

Signs: Ascites & esophageal varices

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3
Q

How are Esophageal Varices caused

A

inc pressure in gastric fungus and esophagus causing swelling in burst..leading to life-threatening GI bleed

Leading cause of death in pts with cirrhosis

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4
Q

Esophageal Varices Treatment options

A

Primary Prophylaxis = BB
Treatment of acute vatical hemorrhage
Secondary prophylaxis

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5
Q

Who doesn’t need Prophylaxis of Varices w/ BB?

A

< 5 mm (w/o red whale marks) & Stage A = only ones who dont need

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6
Q

BB used for EV prophylaxis ?

A

Propranolol and Nadolol

Therapy is life long, bleeding can stop if abrupt D/x

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7
Q

Recommended dosing for EV primary prophylaxis

A

Start propranolol 10mg TID or nadolol 20mg QD if patient has large varices

Titrate to achieve reduction of resting HR by 20-25%, Hit 55-60 bpm, or development of SE

EV ligation is alternative to drug treatment

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8
Q

Acute Variceal Bleeding Pharmacotherapy

A

Octreotide 50 mcg IV bolus followed by continuous infusion 50mcg/h for 3-5 days

More effective and safe compared to vasopressin

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9
Q

Acute Variceal Bleed Band Ligation

A
  1. Elastic band is placed around varix
  2. Strangulation, fibrosis, and obliteration of the varix
  3. As effective as sclerotherapy with fewer complications
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10
Q

Sclerotherapy

A

injecting stuff into varices

causing inflammatory response, leading to thrombus formation and bleeding stops in 2-5min

rebreeding occurs in 50%

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11
Q

Antibiotics to prevent SBP Acute EV bleeding

A

1st line = Moxifloxacin 400mg IV daily X 7 days or Levofloxacin 500mg IV daily for 7 days

  1. Ceftriaxone IV if allergies or areas w/ high FQ resistance

** All pts who undergo acute GI bleed w/ EV **

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12
Q

Refractory Variceal Bleed

A

10-20% fail conventional therapy

    • Shunt surgery only Class A Child-Pugh score
    • TIPS for any Child-Pugh score
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13
Q

When to refer pt for transplantation?

A

Cild-Pugh > 7 and MELD > 7 if have refractory Variceal bleed

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14
Q

Treatment of Acute bleed

A

Endoscopy + Octreotide + 7 days Abx

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15
Q

Secondary Prophylaxis treatments

A
  1. Frequent endoscopic monitoring

2. Beta-blockers

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16
Q

Ascites Pathogenesis Role of albumin

A

Low serum albumin = 3rd spacing of fluid further contributing to decreasing intravascular volume

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17
Q

Assessment of Ascites

A
  1. Stiffing dullness, stigmata of cirrhosis, abdominal circumference
  2. Low cell count, low protein, high SAAG (> 1.1g/dL = portal HTN)
18
Q

Ascites Treatment

A
  1. D/x drinking
  2. Treat underlying liver disease
  3. 2g/day sodium
  4. Spironolactone 100mg/day + furosemide 40mg/day, titrate if needed
19
Q

Ascites Diuretics Dosing

A

Spironolactone 100mg + Furosemide 40mg QD

titrate every few days keeping ratio same, max Spironolactone 400mg/ Furosemide 160mg

20
Q

Rational for Diuretics Combo?

A

Spironolactone used due to Aldosterone Antagonist

21
Q

When do Diuretics get D/c?

A

SrCr > 2mg/dL

Na < 120mEq/L

22
Q

Ascites Monitoring

A

BW, Urine output, abdominal growth
SrCr, Na, K, Urine Na + K
Monitor complications

23
Q

Goal for Ascites therapy?

A

Loss of 0.5kg max weight loss per day

I/O = - 300 to 1000ml

24
Q

Albumin in pts with Ascites

A

Indicated w/ large parecenthesis (> 5L)
Give 6 to 8 g/L removed

Helps prevent ascites recurrence and helps reduce risk of renal failure

25
Q

Pts with SBP, Albumin dosing is….

A

1.5g/Kg within 6 hrs

Additional 1g/kg 3 days later if SrCr > 1 or BUN > 30 or t.bili > 4

26
Q

SBP Diagnosis Criteria

A

PMNS in ascetic fluid > 250 cells/mm3

+ ascitic fluid bacterial culture

27
Q

Antibiotics for SBP

A

Ceftriaxone 1gm IV daily X 7 days

If sever penicillin allergy:
Moxifloxacin 400mg IV or (Levo 500mg) X 7 days

28
Q

Primary Prophylaxis for SBP indicated for pts with…..

A 
Low protein ascites ( < 1.5g/dL)
also...
SrCr > 1.2
BUN > 25
Na < 130
Child-Pugh > 9 or t.bili > 3
29
Q

Secondary Prophylaxis for SBP indicated for….

A

anyone who survived SBP

30
Q

Secondary Prophylaxis for SBP treatment

A

Bactrim DS 1 tab PO daily

use Norfloxacin 400mg PO daily if CrCl < 20ml/min

31
Q

Hepatic Encephalopathy Clinical Signs

A

Changes in mental status
Asterixis = rhythmic movement of hands
Fector hepaticus = fruity breath

32
Q

Hepatic Encephalopathy Grading system

A

0-4, 0 = normal, 4 = coma

33
Q

Treatment plan Hepatic Encephalopathy

A

Protein restriction = 1/1.5g/kg/day (Veg/diary > animal)
Lactulose

Neomycin = no longer used due to high risk of toxicity
Can use Rifamixin
flumazenil, not routinely recommended

34
Q

Lactulose Dosing Hepatic Encephalopathy

A

30-45 mL TID and titrate to 2-3 soft stools per day

also can give as enema

35
Q

Pt education of Lactulose

A

Take 1st dose in morning
Divide rest between meals
If already have 2-3 soft stools, don’t take more

36
Q

Rifamixin Dosing hepatic Encephalopathy

A

550mg PO BID if preferred dosing regime

1st agent added to lactulose for refractory HE

37
Q

When should you decrease Nadolol Dose EV primary Prophylaxis?

A

If HR < 60 or SBP < 90 = resume prior dose

If ClCr < 40 = avoid nadolol

38
Q

Primary method for assessing/severity varices?

A

Endoscopy

multiple grading systems exist for classifying severity of varices

39
Q

Paracentesis indicated when..

A

4-6L of fluid before diuretic therapy is started

Used on ascites refractory to diuretic therapy

40
Q

Common causes of SBP

A

E.coli
Klebsiella pneumonia
pneumococci

41
Q

Treatment of Pruritis due to Hyperbilirubenimia

A

Benadryl or Hydroxyzine

Cholestyramine: 4-16gm/day, reduce Hyperbili

cdm 2 exam 3 (13 decks)

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