Liver

Question 1

Dosing ratio for ascites

Answer 1

Initial: 100 mg spironolactone + 40 mg furosemide
Max: 400 mg spironolactone + 160 mg furosemide
Titrate max q72 hours
Target: max 0.5 kg/day weight loss, up to 1 kg/day (edema)

Question 2

Goals of HBV treatment

Answer 2

• Reduce morbidity & mortality
• Achieve immunologic cure (HBsAg loss with or without seroconversion, sustained HBV suppression)
• HBeAg seroconversion (if positive)

Question 3

Monitoring for HBV treatment

Answer 3

Pre-treatment:
- Serologic test with HAV/HCV/HDV/HIV
- Hepatocellular carcinoma screening
- Fibrosis scanning using elastography

During treatment:
- Relevant side effects with antivirals
- HBV DNA titre
- LFT (esp AST/ALT)
- HBsAg (after undetectable DNA level reached)
- HBeAg and anti-HBe antibody (only after 12 months)

Question 4

Cautions for anti-HBV drugs

Answer 4

• Entecavir (lactic acidosis)
• Tenofovir (nephropathy, lactic acidosis, osteomalacia)
• Lamivudine (pancreatitis, lactic acidosis, resistance)
• Peg-interferon 2a (blood dyscrasia, neuropsychiatric side effects, thyroiditis, cirrhosis decompensation)

Question 5

Doses for anti-HBV drugs

Answer 5

Entecavir 0.5 mg OD
Tenofovir 300 mg OD
Peg-interferon alpha 2a 180 mg SC once weekly

Question 6

Beta blockers for variceal prophylaxis

Answer 6

Carvedilol 6.25 mg BD
Propanolol 20-40 mg BD
Nadolol 20-40 mg OD

Add on EVL q1-4 weeks if for secondary prophylaxis

Question 7

Primary prophylaxis for variceal bleeding

Answer 7

EVL q2-8 weeks OR
BBs
- Propranolol up to 160 mg per day in 2 divided doses
- Carvedilol up to 12.5 mg per day in 2 divided doses
- Nadolol up to 80 mg once a day

Question 8

Management of SBP

Answer 8

• PMN > 250 mm3 in ascitic fluids
• Bacteria: Gram -ve (E. coli, K. pneumoniae) and Gram +ve (S. aureus, E. faecalis, E. faecium)
• DOC: IV Ceftriaxone 1 g/day for 7 days
• Nosocomial concerns: IV Meropenem, Vancomycin
• IV Albumin 25% solution: 1.5 g/kg on day 1, 1 g/kg on day 3

Question 9

Treatment of hepatic encephalopathy

Answer 9

• PO Lactulose 30-45 mL q1-2 hours until catharsis reached
• Titrated to maintenance amount (2-3 loose stools/day)
• PO Rifaximin 550 mg BD for prevention of recurrent HE