Lecture 2 - ESLD Complications

Question 1

Portal Hypertension due to…

Answer 1

Fibrosis in liver interfering with normal blood flow

Question 2

What is Portal Hypertension

Answer 2

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

Signs: Ascites & esophageal varices

Question 3

How are Esophageal Varices caused

Answer 3

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

Question 4

Esophageal Varices Treatment options

Answer 4

Primary Prophylaxis = BB
Treatment of acute vatical hemorrhage
Secondary prophylaxis

Question 5

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

Answer 5

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

Question 6

BB used for EV prophylaxis ?

Answer 6

Propranolol and Nadolol

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

Question 7

Recommended dosing for EV primary prophylaxis

Answer 7

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

Question 8

Acute Variceal Bleeding Pharmacotherapy

Answer 8

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

More effective and safe compared to vasopressin

Question 9

Acute Variceal Bleed Band Ligation

Answer 9

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

Question 10

Sclerotherapy

Answer 10

injecting stuff into varices

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

rebreeding occurs in 50%

Question 11

Antibiotics to prevent SBP Acute EV bleeding

Answer 11

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

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

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

Question 12

Refractory Variceal Bleed

Answer 12

10-20% fail conventional therapy

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

Question 13

When to refer pt for transplantation?

Answer 13

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

Question 14

Treatment of Acute bleed

Answer 14

Endoscopy + Octreotide + 7 days Abx

Question 15

Secondary Prophylaxis treatments

Answer 15

1. Frequent endoscopic monitoring

2. Beta-blockers

Question 16

Ascites Pathogenesis Role of albumin

Answer 16

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

Question 17

Assessment of Ascites

Answer 17

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

Question 18

Ascites Treatment

Answer 18

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

Question 19

Ascites Diuretics Dosing

Answer 19

Spironolactone 100mg + Furosemide 40mg QD

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

Question 20

Rational for Diuretics Combo?

Answer 20

Spironolactone used due to Aldosterone Antagonist

Question 21

When do Diuretics get D/c?

Answer 21

SrCr > 2mg/dL

Na < 120mEq/L

Question 22

Ascites Monitoring

Answer 22

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

Question 23

Goal for Ascites therapy?

Answer 23

Loss of 0.5kg max weight loss per day

I/O = - 300 to 1000ml

Question 24

Albumin in pts with Ascites

Answer 24

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

Helps prevent ascites recurrence and helps reduce risk of renal failure

Question 25

Pts with SBP, Albumin dosing is....

Answer 25

1.5g/Kg within 6 hrs Additional 1g/kg 3 days later if SrCr > 1 or BUN > 30 or t.bili > 4

Question 26

SBP Diagnosis Criteria

Answer 26

PMNS in ascetic fluid > 250 cells/mm3 | + ascitic fluid bacterial culture

Question 27

Antibiotics for SBP

Answer 27

Ceftriaxone 1gm IV daily X 7 days If sever penicillin allergy: Moxifloxacin 400mg IV or (Levo 500mg) X 7 days

Question 28

Primary Prophylaxis for SBP indicated for pts with.....

Answer 28

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

Question 29

Secondary Prophylaxis for SBP indicated for....

Answer 29

anyone who survived SBP

Question 30

Secondary Prophylaxis for SBP treatment

Answer 30

Bactrim DS 1 tab PO daily use Norfloxacin 400mg PO daily if CrCl < 20ml/min

Question 31

Hepatic Encephalopathy Clinical Signs

Answer 31

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

Question 32

Hepatic Encephalopathy Grading system

Answer 32

0-4, 0 = normal, 4 = coma

Question 33

Treatment plan Hepatic Encephalopathy

Answer 33

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

Question 34

Lactulose Dosing Hepatic Encephalopathy

Answer 34

30-45 mL TID and titrate to 2-3 soft stools per day also can give as enema

Question 35

Pt education of Lactulose

Answer 35

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

Question 36

Rifamixin Dosing hepatic Encephalopathy

Answer 36

550mg PO BID if preferred dosing regime 1st agent added to lactulose for refractory HE

Question 37

When should you decrease Nadolol Dose EV primary Prophylaxis?

Answer 37

If HR < 60 or SBP < 90 = resume prior dose | If ClCr < 40 = avoid nadolol

Question 38

Primary method for assessing/severity varices?

Answer 38

Endoscopy multiple grading systems exist for classifying severity of varices

Question 39

Paracentesis indicated when..

Answer 39

4-6L of fluid before diuretic therapy is started Used on ascites refractory to diuretic therapy

Question 40

Common causes of SBP

Answer 40

E.coli Klebsiella pneumonia pneumococci

Question 41

Treatment of Pruritis due to Hyperbilirubenimia

Answer 41

Benadryl or Hydroxyzine Cholestyramine: 4-16gm/day, reduce Hyperbili