Liver Disease

Question 1

What is ascites? (sx)

Answer 1

Fluid accumulation, abdominal pain, shortness of breath

Question 2

What are some tx for ascites?

Answer 2

Paracentesis
Dx: cultures and fluid evaluation
Therapeutic
Reduced SoB
Reduce abdominal pain

Albumin
Diuresis

Question 3

What is the dose for albumin

Answer 3

6-8 g/L for > 5 L of fluid pulled off
depends on amount of fluids removed

Question 4

What can be used for diuresis?

Answer 4

Spironolactone 50 mg
Furosemide 20 mg
Sodium restriction diet → 2 g or less/day
2.5:1 Ratio of spironolactone to furosemide

Question 5

what should be monitored w ascites?

Answer 5

Sx of ascites (should decrease)
Ascitic fluid evaluation and cultures
Electrolyte disturbances → Na, K, SCr

Question 6

What is hyponatremia?

Answer 6

(Na < 120 mEq/L) → commonly seen in > 40% of patients w ascites

Question 7

What are options for hyponatremia tx?

Answer 7

Hypertonic saline (3% normal saline boluses)
Hold diuretic therapy if applicable

Question 8

What should be monitored w hyponatremia?

Answer 8

Appropriate sodium correction
Increase Na 4-6 mEq/L, not to exceed 8 mEq/L per 24 day period
Avoid osmotic demyelinating syndrome (ODS)

Question 9

What are some lab indicators for spontaneous bacterial peritonitis (SBP)?

Answer 9

Total protein < 1.5 g/dL
Bilirubin > 2.5 mg/dL
SCr > 1.2 mg/dL
Na < 130 mEq/L
BUN > 25 mg/dL

Question 10

What are options for SBP tx?

Answer 10

Antibiotics: ceftriaxone 1 g once daily
Day 1: albumin 1.5 g/kg (do not exceed 100 g of albumin per day)
Day 3: albumin 1 g/kg (do not exceed 100 g of albumin per day)

Question 11

What should be monitored w SBP?

Answer 11

Ascitic fluid evaluation
PMNs < 250 cells/mm3
cultures/susceptibilities → Abx changes, escalation or de-escalation
Duration: 5-7 days, if escalated to tx

Question 12

What is hepatorenal syndrome (HRS-AKI)

Answer 12

SCr rise > 0.3 mg/dL

Question 13

What are some tx for HRS-AKI?

Answer 13

Octreotide
SQ 100 mcg q 8 hours OR
IV 50 mcg/hr

Midodrine
5 mg q 8 hours, titratable to 15 mg q 8 hours
Monitor BP/HR

Question 14

What should be monitored w HRS-AKI?

Answer 14

urine output, SCr, vital signs

Question 15

What are some options for hepatic encephalopathy?

Answer 15

Lactulose 20 g TID AND
Rifaximin 550 mg TID
Titrate to 2-3 bowel movements per day

Question 16

What should be monitored for hepatic encephalopathy?

Answer 16

Cognition and visual hallucination

Question 17

How should the dose for ceftriaxone changes from primary ppx use to tx?

Answer 17

Ceftriaxone 1 g daily –> Ceftriaxone 2 g daily

Question 18

What can be used for secondary ppx use for STEMI?

Answer 18

Bactrim 1 DS once daily
Ciprofloxacin 500 mg once daily

Question 19

How is portal HTN and esophageal varices bleeds dx?

Answer 19

Hepatic Venous Pressure Gradient (HVPG) > 10 mm Hg

Question 20

What is the tx for portal HTN and esophageal varices bleeds?

Answer 20

Non-selective beta blockers (propranolol, carvedilol)
Acute variceal bleeding→ ceftriaxone 1 g daily
Vasoactive meds → octreotide, terlipressin, etc
EGD within 12 hours → hemodynamics stable
EVL→ variceal ligation, if varices identified
TIPS procedure, if refractory to other tx modalities

Question 21

What should be monitored for portal HTN and esophageal varices bleeds?

Answer 21

Evidence of bleeding
Vomiting blood
Blood in stool
Annual endoscopic screening

Question 22

How should you approach Alcohol withdrawal? (CIWA)

Answer 22

Lorazepam
Scheduled taper, if sx are severe and alcohol use is substantial
As needed protocol: doses provided if patient scores on CIWA

Librium
Same tx modalities as lorazepam

Question 23

What is used for Wernicke’s PPx?

Answer 23

thiamine and folic acid