Lecture 2 - ESLD Complications Flashcards
Portal Hypertension due to…
Fibrosis in liver interfering with normal blood flow
What is Portal Hypertension
When portal blood flow is impeded and portal pressure exceeds 12 mmHg
Signs: Ascites & esophageal varices
How are Esophageal Varices caused
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
Esophageal Varices Treatment options
Primary Prophylaxis = BB
Treatment of acute vatical hemorrhage
Secondary prophylaxis
Who doesn’t need Prophylaxis of Varices w/ BB?
< 5 mm (w/o red whale marks) & Stage A = only ones who dont need
BB used for EV prophylaxis ?
Propranolol and Nadolol
Therapy is life long, bleeding can stop if abrupt D/x
Recommended dosing for EV primary prophylaxis
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
Acute Variceal Bleeding Pharmacotherapy
Octreotide 50 mcg IV bolus followed by continuous infusion 50mcg/h for 3-5 days
More effective and safe compared to vasopressin
Acute Variceal Bleed Band Ligation
- Elastic band is placed around varix
- Strangulation, fibrosis, and obliteration of the varix
- As effective as sclerotherapy with fewer complications
Sclerotherapy
injecting stuff into varices
causing inflammatory response, leading to thrombus formation and bleeding stops in 2-5min
rebreeding occurs in 50%
Antibiotics to prevent SBP Acute EV bleeding
1st line = Moxifloxacin 400mg IV daily X 7 days or Levofloxacin 500mg IV daily for 7 days
- Ceftriaxone IV if allergies or areas w/ high FQ resistance
** All pts who undergo acute GI bleed w/ EV **
Refractory Variceal Bleed
10-20% fail conventional therapy
- Shunt surgery only Class A Child-Pugh score
- TIPS for any Child-Pugh score
When to refer pt for transplantation?
Cild-Pugh > 7 and MELD > 7 if have refractory Variceal bleed
Treatment of Acute bleed
Endoscopy + Octreotide + 7 days Abx
Secondary Prophylaxis treatments
- Frequent endoscopic monitoring
2. Beta-blockers
Ascites Pathogenesis Role of albumin
Low serum albumin = 3rd spacing of fluid further contributing to decreasing intravascular volume
Assessment of Ascites
- Stiffing dullness, stigmata of cirrhosis, abdominal circumference
- Low cell count, low protein, high SAAG (> 1.1g/dL = portal HTN)
Ascites Treatment
- D/x drinking
- Treat underlying liver disease
- 2g/day sodium
- Spironolactone 100mg/day + furosemide 40mg/day, titrate if needed
Ascites Diuretics Dosing
Spironolactone 100mg + Furosemide 40mg QD
titrate every few days keeping ratio same, max Spironolactone 400mg/ Furosemide 160mg
Rational for Diuretics Combo?
Spironolactone used due to Aldosterone Antagonist
When do Diuretics get D/c?
SrCr > 2mg/dL
Na < 120mEq/L
Ascites Monitoring
BW, Urine output, abdominal growth
SrCr, Na, K, Urine Na + K
Monitor complications
Goal for Ascites therapy?
Loss of 0.5kg max weight loss per day
I/O = - 300 to 1000ml
Albumin in pts with Ascites
Indicated w/ large parecenthesis (> 5L)
Give 6 to 8 g/L removed
Helps prevent ascites recurrence and helps reduce risk of renal failure
Pts with SBP, Albumin dosing is….
1.5g/Kg within 6 hrs
Additional 1g/kg 3 days later if SrCr > 1 or BUN > 30 or t.bili > 4
SBP Diagnosis Criteria
PMNS in ascetic fluid > 250 cells/mm3
+ ascitic fluid bacterial culture
Antibiotics for SBP
Ceftriaxone 1gm IV daily X 7 days
If sever penicillin allergy:
Moxifloxacin 400mg IV or (Levo 500mg) X 7 days
Primary Prophylaxis for SBP indicated for pts with…..
Low protein ascites ( < 1.5g/dL) also... SrCr > 1.2 BUN > 25 Na < 130 Child-Pugh > 9 or t.bili > 3
Secondary Prophylaxis for SBP indicated for….
anyone who survived SBP
Secondary Prophylaxis for SBP treatment
Bactrim DS 1 tab PO daily
use Norfloxacin 400mg PO daily if CrCl < 20ml/min
Hepatic Encephalopathy Clinical Signs
Changes in mental status
Asterixis = rhythmic movement of hands
Fector hepaticus = fruity breath
Hepatic Encephalopathy Grading system
0-4, 0 = normal, 4 = coma
Treatment plan Hepatic Encephalopathy
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
Lactulose Dosing Hepatic Encephalopathy
30-45 mL TID and titrate to 2-3 soft stools per day
also can give as enema
Pt education of Lactulose
Take 1st dose in morning
Divide rest between meals
If already have 2-3 soft stools, don’t take more
Rifamixin Dosing hepatic Encephalopathy
550mg PO BID if preferred dosing regime
1st agent added to lactulose for refractory HE
When should you decrease Nadolol Dose EV primary Prophylaxis?
If HR < 60 or SBP < 90 = resume prior dose
If ClCr < 40 = avoid nadolol
Primary method for assessing/severity varices?
Endoscopy
multiple grading systems exist for classifying severity of varices
Paracentesis indicated when..
4-6L of fluid before diuretic therapy is started
Used on ascites refractory to diuretic therapy
Common causes of SBP
E.coli
Klebsiella pneumonia
pneumococci
Treatment of Pruritis due to Hyperbilirubenimia
Benadryl or Hydroxyzine
Cholestyramine: 4-16gm/day, reduce Hyperbili
