Liver Flashcards
Which 3 groups of patients with cirrhosis, do not need variceal screening with EGD?
Upper endoscopy should be performed in any
patient with cirrhosis to screen for varices, with
the exception of those with compensated cirrhosis,
a platelet count above 150,000 platelets/μL, and
a liver stiffness measurement below 20 kPa.
Under what level kPa for liver stiffness do you not have to get an EGD for variceal screening?
liver stiffness measurement below 20 kPa does not require EGD
If no varices are seen on EGD, how often should patients with compensated cirrhosis have an EGD (ongoing liver disease/injury vs not having ongoing liver insult)?
If no varices are found in a patient with compensated
cirrhosis, recommendations are for a screening
endoscopy to be repeated every 2 years in those
with ongoing liver injury and every 3 years in
those without ongoing liver injury.
Under what platelet number, are patients at increased risk of varices and should have an EGD?
Under 150k
In individuals with cirrhosis and varices that have not bled, who are taking nonselective BB, how often should endoscopy be done?
In addition, in individuals with varices
that have not bled, endoscopy does not need to
be repeated in patients who are taking NSBBs.
Patients with HCC with should be referred for liver transplantation, if they are within Milan criteria? what is Milan criteria
Milan criteria (single mass <5 cm or up to 3 masses <3 cm each, in the absence of vascular invasion or metastatic disease). Liver
transplantation will provide him his best chance for
long-term survival. While awaiting transplantation,
he can undergo locoregional therapies to control
his tumor burden.
what are some of the cirrhotic related clinical manifestations that make a cirrhotic patient with HCC a poor surgical candidate?
underlying clinically significant portal hypertension (as evidenced by his large esophageal varices, thrombocytopenia, and splenomegaly) make a pt a poor resection candidate.
what is the likelihood of a patient with AIH, having recurrent disease after transplantation?
Patients with AIH usually require higher doses
of baseline immunosuppression after transplantation. Individuals with AIH have an approximately 20% chance of recurrent disease after transplantation. This risk is higher if immunosuppression is rapidly tapered after transplantation, and most centers manage patients with a higher baseline level of immunosuppression compared with recipients with other etiologies of liver disease.
Should pts with new decomp cirrhosis 2/2 HCV, have treatment of HCV prior to traplsant?
All patients with HCV infection should be considered for therapy, given the tolerability and efficacy of direct-acting antiviral therapies. In those awaiting transplantation, however, treatment decisions need to be made on a case-by-case basis, as there are a variety of potential risks and benefits with each treatment strategy. Potential benefits of
treatment before transplantation include stabilizing or improving liver function before surgery and preventing liver graft infection at transplantation. Potential risks of treatment before transplantation include having higher rates of treatment failure with decompensated liver disease and
that successful treatment may leave patients with
a diseased liver but improve their MELD score
enough to limit access to organs (often referred
to as “MELD purgatory”).
what 3 findings can you see in patients with hepatopulmonary syndrome?
hepatopulmonary syndrome
based off the presence of underlying liver disease,
impaired oxygenation, and evidence of intrapul-
monary vascular shunting.
in patients with hepatopulmonary syndrome, what can be expected to be seen on ABG?
When present, an arterial blood gas should be obtained with the expectation of an elevated alveolar-arterial gradient and a reduced PaO2. aFTER liver transplantation , pts can expect gradual improvement in his hypoxia over
the next 6 to 12 months.
Does TIPS help to improve hepatopulmonary syndrome?
Response to medical therapies is overall ineffective and response to transjugular intrahepatic portosystemic shunt
has been reported with variable results and is not generally recommended.
Muscle cramps in cirrhotic patients are common. Can muscle cramps in cirrhotic patients be treated?
The cramps related to her liver disease can be improved with multiple different supplements including the use of agents such as baclofen, vitamin E, and taurine.
can pts with acute liver failure receive urgent liver transplant? what is the major exclusion criteria to getting a transplant in this situation?
One of the most feared
outcomes of transplantation, however, is failing to
recover neurological function. Objective evidence
of brainstem injury (with fixed and dilated pupils a) should preclude transplantation as it is likely to be futile.
are Bacterial infection or psychiatric disease contraindications to liver
transplantation?
Bacterial infection and psychiatric disease are
relative contraindications but should not preclude
transplantation.
Which cirrhotic variceal patients need early TIPS?
Several studies have suggested benefit with early TIPS for individuals who present with variceal hemorrhage. TIPS placement should be reserved for individuals who meet inclusion criteria of studies that have shown benefit. The population that is often referenced in this setting are those who present with a variceal hemorrhage and are Child-Pugh class C (score 10-13) or Child-Pugh class B (score 7-9) with active hemorrhage on endoscopy.
What are 3 exclusion criteria for early TIPS for variceal bleed?
Notably renal disease, age above 75 and Child-Pugh class A cirrhosis were exclusion criteria for TIPS.
how can liver massHCC be diagnosed on imaging? whats the best imaging for this?
liver mass on ultrasound, which is highly concerning for HCC if baseline cirrhosis.
Diagnosis can often be made without biopsy, when
dynamic imaging of the liver (either CT with contrast or MRI)
reveals the typical features of HCC (arterial
hypervascularity and early washout in the portal
venous phase).
Radiologically, what are the typical features of HCC?
The typical features of HCC (arterial
hypervascularity and early washout in the portal
venous phase)
Which CT imaging is best to radiographically diagnoise HCC?
CT imaging is not adequate to evaluate for HCC IF done without contrast. HCC would not be evident on noncontrast CT imaging of the liver and could easily be missed on a single-
phase CT of her abdomen (which would have onlyobtained a venous phase).
in cirrhotic patients, whats the max daily Tylenol dose you can give?
When systemic medications are needed, acetaminophen is considered safe and is the recommended first-line
pharmacologic therapy for pain in this population,
at a dose of up to 2000 mg daily.
In alcoholic hepatitis, if patients do not have improvement in Lille score and score is consistent with nonresponse to
medical therapy, should they continue steroids with Prednisolone?
Pts should stop prednisolone and be referred to a tertiary center for considerations of early transplantation as
individuals with severe alcoholic hepatitis that did not respond to
glucocorticoid therapy were found to have a markedly improved 6-month survival if
they underwent early liver transplantation,
Does older age necessarily prevent you from being a liver transplant candidate?
It is generally accepted that physiological, not chronological, age should determine who is a
candidate for liver transplantation. Older patients can be listed for liver transplantation after careful considerations of their comorbidities and
functional status.
Under what circumstance should patients with CKD and liver disease, be listed for liver and kidney transplant?
If kidney disease worsens after liver transplantation, the patient can be listed for kidney transplantation and will be prioritized on the list/ If the patient has underlying chronic kidney disease it may very likely worsen after transplantation related to the acute stressors of
surgery and side effects of medications he will
likely receive. The Organ Procurement and Transplantation Network established medical eligibility for those who are candidates for simultaneous liver kidney transplantation (SLK)
that included a “safety net” allocation priority for
individuals who undergo liver transplantation
alone and develop new or ongoing progressive
renal impairment.
Which liver transplant patients, are eligible for an SLK?
Individuals are eligible for an SLK if they have
a sustained acute kidney injury (≥6 weeks of requiring ≥once-weekly dialysis or a GFR of ≤25 mL/min tested weekly) or chronic kidney
disease (GFR ≤60 mL/min for >90 days and a
subsequent worsening of renal function of GFR
≤30 mL/min or need for regular dialysis). The
hope in those not meeting these criteria is that
their renal function may recover, minimizing the
transplantation of kidneys into individuals who
may not need them.
what is the treatment for pts with patient has evidence of portal hypertensive
gastropathy (PHG)?
If patient has evidence of portal hypertensive
gastropathy (PHG), First-line therapy consists of
iron supplementation for anemia and nonselective
beta-blockers. Transjugular intrahepatic portosys-
temic shunt can be considered if first-line measures fail, although its overall efficacy is not clear.
what is the recommended caloric intake for cirrhotics with sarcopenia?
In this setting, specific recom-
mendations should be given regarding total caloric (30-35 kg/kg daily) and protein (1.2-1.5 g/kg daily) intake for any individual with cirrhosis.
In cirrhotic patients, what is the negative effect of patients fasting on muscle mass?
This patient is fasting for prolonged periods of
time (roughly 16 hours a day between meals),
which will lead to worsening of his sarcopenia.
if cirrohtic pts with variceal bleed, what tx is recommended to prevent
rebleeding in this population?
Individuals who survive an episode of acute vari-
ceal hemorrhage have a bleeding risk of around
60% if untreated. Current recommendations are
for a combination of EVL and NSBB to prevent
rebleeding in this population. as combination therapy has been shown
to be superior to EVL alone at preventing re-
bleeding. TIPS is incorrect and recommended as
a rescue therapy in those who experience recur-
rent bleeding despite management with EVL and
NSBB combination therapy.
when is TIPS used for variceal bleed?
TIPS is recommended as a rescue therapy in those who experience recurrent bleeding despite management with EVL and NSBB combination therapy.
can pts with early-stage unresectable hilar cholangiocarcinoma be candidates for liver transplant?
Transplantation is now considered an option in many centers in those with early-stage unresectable hilar cholangiocarcinoma after data published from the Mayo Clinic showed acceptable outcomes in a highly selected cohort of patients. In those who
were candidates, patients received neoadjuvant
therapy that included both radiation and sys-
temic chemotherapy
Which is the main reason patients with would not be a candidate for liver transplant?
Transplantation centers have since developed
individualized protocols for transplantation for early-stage hilar cholangiocarcinoma. In addition to a requirement for neoadjuvant therapy and repeat staging after treatment, the Organ
Procurement and Transplantation Network mandates that transperitoneal biopsy (either by endoscopic ultrasound or percutaneous approaches) be an exclusion criterion in any
institutional protocol.
How does portal hypertensive gastropathy appear described on endoscopy?
This patient has evidence of portal hypertensive
gastropathy (PHG). Upper endoscopy reveals a mosaic mucosal pattern with a “snake-skin” appearance.
If first line therapy for PHG (NSBB) fails, what can be considered next?
TIPS
WHICH clinical phenomenon is asociated with upper endoscopy
reveals multiple red spots and linear areas of erythema converging on the pylorus?
First-line therapy consists of endoscopic electrocoagulation or laser therapy and multiple sessions are often needed. For refractory cases, surgical antrectomy can be performed, albeit with significant
morbidity.
what is the first line treatment for GAVE? Then what is treatment if refractory
First-line therapy consists of endoscopic electrocoagulation or laser therapy and multiple sessions are often needed. For refractory cases, surgical antrectomy can be performed, albeit with significant
morbidity.
What is the one treatment that have shown to help resolve GAVE?
A variety of case reports and case series have shown that GAVE can resolve after liver transplantation. No medication has been clearly shown to be beneficial for the treatment of GAVE.
In terms of therapies, does bleeding from GAVE respond
to measures that reduce portal pressure?
Unlike portal hypertensive gastropathy and
varices, bleeding from GAVE does not respond
to measures that reduce portal pressure.
For cirrhotic pts with sleep problems, what 3 meds can be used for the short term?
Sleep disturbances are relatively common in individuals with cirrhosis. When present, clinicians should consider inadequately treated hepatic encephalopathy (which can lead to sleep-wake
reversal) as well as sleep hygiene, which includes
ensuring lactulose and diuretics are timed to avoid
nocturnal awakenings. Medications that have been
studied in small randomized controlled trials for
sleep disturbances in cirrhosis include melatonin,
zolpidem, and hydroxyzine.
How is bleeding from GOV type 1 gastric varices managed compared to esophageal varices?
type 1 gastric varices (GOV1) are located along the lesser curvature of the stomach. Bleeding from GOV1 should be managed
similarly to bleeding from esophageal varices.
Where are type 1 gastric varices (GOV1) located?
type 1 gastric varices (GOV1) are located along the lesser curvature of the stomach. Gastroesophageal varix (GOV) type 1: Extension of esophageal varices along lesser CURVATURE OF STOMACH
in the setting of cirrhosis and variceal bleed, with type 2 or 3 GOV varices, when is splenectomy considered?
Splenectomy can be considered in the presence of splenic vein
thrombosis.
Where are GOV2 varices located?
Gastroesophageal varix type 2: Extension of esophageal varices along great curvature
In patients with alcohol cirrhosis, who have improvement in clinical status and go from decompensated to compensated status, with a low MELD and low (class A child pugh), is liver transplant indicated?
Although transplantation is clearly beneficial in individuals with advanced liver disease with high MELD scores, a survival advantage with transplantation is only seen after MELD scores are greater than 17.
Are patients with end-stage hepatocellular carcinoma (Barcelona Clinic Liver Cancer stage D), poor functional status and poor liver function (Child-Pugh class C) candidates for chemo or liver transplant?
This patient has end-stage hepatocellular carcinoma (Barcelona Clinic Liver Cancer stage D) given his poor functional status and poor liver function (Child-Pugh class C). This corresponds to a poor
survival (<3 months) and treatment should be
supportive. He is not a transplantation candidate based off tumor burden and vascular invasion (outside of “Milan criteria”).
Which set of criteria refer to a single tumor of 5 cm or less or three tumors that are each 3 cm or less, no macrovascular invasion, and no metastasis?
The Milan criteria state that transplantation should be performed in those with a single tumor of 5 cm or less or three tumors that are each 3 cm or less, no macrovascular invasion, and no metastasis. Patients who do not meet the Milan criteria are not considered eligible candidates for liver transplantation.
What is the milan criteria used for? what are the components of milan criteria?
The Milan criteria state that transplantation should be performed in those with a single tumor of 5 cm or less or three tumors that are each 3 cm or less, no macrovascular invasion, and no metastasis. Patients who do not meet the Milan criteria are not considered eligible candidates for liver transplantation.
In evaluating a patient for transplant, if they have evidence of pulmonary hypertension (with right ventricular
systolic pressure [RVSP] > 45 mmHg), is this a deal breaker for transplant?
If the right heart catheterization is consistent with severe
pulmonary hypertension (mean pulmonary artery
pressure [MPAP] > 45 mmHg), should be
considered a contraindication to transplantation if
this cannot be improved. A Mayo Clinic case series
showed a 100% mortality in those who received a
transplant with an MPAP greater than 50 mmHg, and current guidelines only recommend pursuing transplantation if these patients achieve an adequate response to medical therapy.
What are the 3 different nonselective beta-blockers that can be recommended for primary prophylaxis in individuals with cirrhosis
and medium/large varices that have not bled?
(nadolol, propranolol, and carvedilol)
Above what number BMI, is a relative contraindication to transplantation (but not an absolute contraindication)?
Body mass index greater than 40 kg/m2 is a relative contraindication to transplantation (but not an absolute contraindication).
In cirrhotic variceal patients, WHO HAVE NEVER BLED, is it better to band them or give them NSBB?
dO ONE OR THE OTHER. Endoscopic variceal ligation has been shown in randomized controlled trials to be as effective as nonselective beta-block-ers for primary prophylaxis. The combination of NSBB and variceal ligation has been associated with more side effects without reduction in
variceal hemorrhage risk in this population that
has not had active bleeding.
What is The most important predictor of
variceal hemorrhage?
The most important predictor of variceal hemorrhage is the size of the varices, with individuals with large varices experiencing their
first hemorrhage at a rate of 15% per year.
Aside from the size of varices, what two other factors are important risk factors for re-bleeding from varices in cirrhotic with varices?
Other predictors of bleeding are the presence of red wale signs on
endoscopy and Child-Pugh class B or C cirrhosis.
Can TIPS be used for the primary prophylaxis for prevention of variceal bleed?
TIPS placement is not
recommended for the primary prophylaxis based
off trials of prophylactic surgical shunts showing a
higher rate of encephalopathy and a trend toward
higher mortality.
