Liver Flashcards
what is the liver responsible for
bile production
drug/food/toxin metabolism
protein synthesis (albumin / coag)
storage viatmins
AST and ALT levels with acute liver injury
AST > 50
ALT > 50
alk phos > 120
are LFTs indicators of liver function?
no just mark acute injury
what are markers of acute liver injury
increased, ALT, AST, alk phos, bilirubin
chronic liver disease labs
decreased albumin
increased INR
increased bilirubin
incidence of drug induced liver injury
0.02%
classifications of drug induced liver injury
direct hepatotoxicity
idiosyncratic hepatotoxicity
indirect hepatotoxicity
direct hepatotoxicity drug causes
acetaminophen
IV amio
IV methotrexate
idiosyncratic hepatotoxicity drug causes
mycins
penicillins
cephalosporines
floxacins
indirect hepatotoxicity causes
metabolic abnormalities causing alcoholic fatty liver disease
which meds cause drug induced liver injury
acetaminophen
penicillins
cephalosporins
floxacins
mycins
isoniazid
what to do if we suspect DILI
hold agent
acetaminophen toxicity usaully what dose
8g at once
toxic metabolite from acetaminophen toxicity
NAPQI
direct hepatotox
signs of acetaminophen tox
N/V
abdominal pain
jaundice
how do we reverse acetaminophen
if within 1-2 hours give activated charcoal
N-acetylcysteine chart after 4 h
how does NAC work
binds NAPQI and decreases the toxic effects
N-acetylcystine dosing oral
140 mg/kg loading
70 mg/kg q4h x 72 h
N-acetylcysteine dosing IV
1st: 150 mg/kg over 1 hr (15g max)
2nd: 50 mg/kg over 4 h (5g max)
3rd: 100 mg/kg over 10 h (10g max)
what to monitor with NAC
AST
ALT
q12-24 h
s/sx
what is cirrhosis
severe, chronic irrversible fibrosis of liver
causes of cirrhosis
alcohol use
viral hepatitis
drugs (amio, methotrexate)
symptoms of cirrhosis
jaundice
fatigue
weight loss
ascites
hepatomegaly/splenomegaly
enchephalopathy
how do we confirm diagnosis of cirrhosis
liver biopsy
what does MELD predict
3 month mortality risk
used in transplant list
ascites symptoms
abdominal distension
abdominal pain
SOB
nausea
how do ascites happen
increased pressures with portal HTN drive fluid into peritoneal space
compensatory mechanisms result in fluid retention
decrease albumin
ascites non-pharm treatment
low sodium diet
assess for liver transplant
ascites first line
aldosterone antagonist + loop diuretic
ascites second line
paracentesis
what class of meds to avoid in pts with cirrhosis
NSAIDs
diuretic dosing ascites
spironolactone 100: furosemise 40
5:2 ratio
max 400/160
titrate every 3-5 days
if we have to do monotherapy in ascites what should we do
spironolactone
side effects from spironolactone
hyperkalemia
AKI
gyneco
side effects from furosemide
AKI
decreased potassium
monitroing in spiro/loop treatment
SCr, K+
paracentisis treatment outline
if > 5L fluid lost: 25% albumin IV 6-8g per L removed
does albumin for paracentisis help with mortalituy
yes
what are varices
small offshoots in the esphagus
can burst and cause variceal bleeding
risk factors for variceal bleeding
size of varices
cirrhosis severity
red color
alcohol use
what can prevent variceal bleeding first line
non selective BBs
EVL (bands)
not for use together
does variceal bleeding prophylaxis impact mortality
no
non selective BB MOA
only in moderate disease
beta I and II antagonism
decreased HR and CO
vasoconstriction
non selective beta blockers options
nadolol
propranolol
carvedilol
nadolol dosing
20-40 mg PO daily
max: 80 (ascites), 160 (no ascites)
propranolol dosing
20-40 mg PO BID
max:160 mg (ascites), 320 (no ascites)
carvedilol dosing
6.25 mg PO daily
max: 12.5 mg PO daily
how to titrate BBs
to HR < 60
every 3 days till goal
keep SBP > 90
what is EVL
endoscopic variceal ligation
bands off varices
variceal bleeding presentation
visualized via endoscopy
hematemeiss
melena
fatigue
dizzy
hypo
gold standard for variceal bleeding reatment
EVL
what do we give at first sign of variceal bleeding
blood transfusion
octreotide
antibiotic prophylaxis
what is ocreotide
vasoconstrictor and decrease blood flow
what is ocreotide indicated in
variceal bleeds only
how long do we use ocreotide
2-5 days or 24 h after EVL
side effect monitoring of ocreotide
BP
HR
BG
N/V
goal EVL initation in variceal bleed
within 12 hours
antibiotic prophylaxis in variceal bleeding
ceftriaxone up to 7 days
until hemorrhage gone
is ceftriaxone renally cleared
no
what drug not reccommended in variceal bleed
Vit K
secondary prophylaxis of variceal bleeding
EVL q 1-2 weeks
non selective BBs
what is SBP
spontaneous bacterial peritonitis
bacterial translocation when bacteria cross intestinal barrier
presentation of SBP
fever
abdom pain/tender
leukocytosis
encephalopathy
some asymptomatic
how do we diagnose SBP
positive ascitic fluid culture
> 250 cells/PMN
PMN = WBC x % neutrophils
how to treat SBP
ceftriaxone
5-7 days
albumin
ceftriaxone side effect
diarrhea
albumin dosing SBP
day 1: 1.5 g/kg x 1 (within 6 h)
day 3: 1 g/kg x 1
SBP secondary prevention
Bactrim or cipro
avoid PPIs
bactrim dosing SBP prevention
800/160 mg once daily
ciprofloxacin SBP prevention dose
500 mg once daily
monitoring for cipro and bactrim for SBP secondary prophy
CBC, SCr, electrolytes
how long do we give secondary prophylaxis in SBP
indefinite
hepatic encephalopathy first line treatment
lactulose
target >2 BMs per day
