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Therapeutics IV Final Subjects > Liver Disease > Flashcards

Liver Disease Flashcards

1
Q

What are some different functions of the liver?

A 
Filtration of blood
secretion of bile
excretion of bilirubin
metabolic functions
conversion of sugar to glycogen
glycogen storage
protein and lipid synthesis
production of clotting factors
lipid and ammonia-urea cycle
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2
Q

What are some causes of liver disease?

A 
viral infections
drugs and toxins
biliary obstruction
inbonrn erros of metabolism
CV
Autoimmune
cryptogenic
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3
Q

What are the different types of liver disease?

A

Acute vs chronic
focal vs diffused
mild vs severe
reversible vs irreversible

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4
Q

What are the most common causes of chronic liver siease and cirrhosis?

A

Alcohol and HCV

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5
Q

What are two immediate life-threatening complications?

A

Acute variceal bleeding and spontaneous bacterial peritonitis

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6
Q

The liver recieves blood from the _______ artery and the ______ vein.

A

hepatic artery and the portal vein

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7
Q

Where does the blood from the portal vein come from?

A

The mesenteric, gastric, splenic and pancreatic veins

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8
Q

What is the definition of cirrhosis?

A

chronic disease of the liver with widespread hepatic cell injury and hepatocyte destruction

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9
Q

Inflammation in hepatocytes causes what?

A

permanent hepatic scarring and deposition of fibrous material

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10
Q

Fibrosis ______ the normal blood flow through the liver

A

disrupts

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11
Q

resistance to portal blood flow results in what?

A

persistent and progressive elevations in portal blood pressure or portal hypertension

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12
Q

What are some sxs of cirrhosis?

A

pruritus, jaundice, hyperpigmentation

ascites, edema, malaise,anorexia, weight loss

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13
Q

What are some abnormal lab tests for cirrhosis?

A

hypoalbuminemia, elevated prothrombin time, thrombocytopenia, inc AP, inc LFTs

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14
Q

What are Liver Function tests?

A

AST, ALT, AP, GGT, glotting factors (abnormal), bilirubin

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15
Q

How long can GGT be elevated?

A

for up to 3 wks

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16
Q

At ESLD will you see abnormal LFTs?

A

No

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17
Q

What is the Child-Pugh classification of Liver Disease?

A

A way to classify liver disease based on life expectancy and 1-yr survival

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18
Q

What is another liver disease classification system?

A

The Model for End Stage Liver Disease (MELD)

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19
Q

What lab values does the MELD score use?

A

bilirubin, INR, SCr

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20
Q

What is the Meld equation?

A

3.8xLn(bilirubin) + 11.2xLn(INR) + 9.6xLn(Scr) + 6.4

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21
Q

What does the MELd score tell you?

A

Risk of dying while waiting for a transplant

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22
Q

What are some clinical manifestations ofl iver disease?

A 
portal hypertension
gastroesophagel varices and bleeding
acites
spontaneious bacterial peritonitis
hepatic encephalopathy
hepatorenal syndrome
coagulopathy
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23
Q

What causes portal hypertension?

A

inc portal pressure from:
1) structural resistnace to blood flow
2) intrahepatic vasoconstriction
Hepatic venous pressure gradient (normally 3-5) - its 10-12 in cirrhosis with varices

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24
Q

How do you diagnose gastroesophageal varices?

A

esophagogastroduodenoscopy (EGD)

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25
Q

What is given to prophylaxis of portal hypertension and variceal bleeding?

A

nonselective beta blockers (Propranolol 20mg BID or nadolol 20-40mg QD) or carvidolol

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26
Q

How is the dose escalated in propranolol or nadolol?

A

dec HR 20-25% or 55beats/min

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27
Q

How long do you need to use propranolol for prophylaxis of portal hypertension or variceal bleeding?

A

indefinitely unless not tolerated

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28
Q

What are some CI of propranolol?

A 
Asthma/COPD
Insulin-dependent diabetes - blocks side effects of diabetes
peripheral vascular disease
Heart block, bradycardia
uncompensated CHF
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29
Q

What are some side effects of Propranolol?

A

Fatigue, SOb, lightheadedness

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30
Q

Do you prophylax on the formation of variceal polyps or just on them popping and bleeding?

A

on them popping and bleeding

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31
Q

AASLD guidelines recommend against prophylaxis use of:

A

Nitrate monotherapy
nitrate + nonselective beta blockers
carvedilol (not first line)

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32
Q

What are some risk factors of acute variceal bleeding?

A

Alcohol and NSAIDs

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33
Q

If the HVPG is greater than ___ you have difficulty controling bleeding, higher risk of early rebleeding and a higher 1yr mortality riate

A

> 30mmHg

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34
Q

For an acute variceal bleed what should you give to prevent infection?

A

Prophylactive antibiotics for a max of 7 days:
Norfloxacin
Ciprofloxacin
IV ceftriaxone

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35
Q

What is Octreotide used for?

A

acute variceal bleed
iv bolus and then continuous infuction;
continued for 3-5 days after diagnosis confirmed

36
Q

what is Endoscopic varceal ligation?

A

Tie off nodules to slough them off

37
Q

Should beta blockers be used in the acute variceal bleed?

A

No

38
Q

What type of surgical options are there for portal hypertension and varceal bleeding?

A

transjugular intrahepatic portosystemic shunt, dec vascular resistance,

39
Q

What is the TIPS procedure?

A

putting a connection between the portal vein and hepatic vein and using stent to open up a new vein formation to dec pressure

40
Q

Ascites is a complication of _______

A

cirrhosis

41
Q

What is ascites?

A

accumulation of fluid in peritoneal cavity

42
Q

Portal hypertension leads to peripheral vasodilation which leads to _____________–

A

compensatory Na and water retention

43
Q

How do you tx Ascites?

A

Underlying cause
alcoholic hepatitis - abstinenece and time
HBV cirrhosis - antiviral therapy
Dietary salt restriction (2g/day)
fluid restriction
diuretics (spironolactone 100mg and Furosemid 40mg)

44
Q

Consider holding diuretics if what?

A

Uncontrolled/recurrent hepatic encephalopathy

serum Na 2 mg/dL

45
Q

Should liver transplantation be considered in patients with cirrhosis and ascites?

A

Yes

46
Q

For Refractory ascites what are the tx options?

A

Paracentesis + albumin

TIPS procedure

47
Q

What is SBP?

A

Spontaneous Bacterial Peritonitis

Infection of abdominal cavity due to ascites and portal hypertension

48
Q

What are some sxs for SBP?

A 
abdominal pain/tendernes
fever/chills
tachycardia
hepatic encephalopathy
altered WBC
49
Q

How do you diagnose SBP?

A

positive ascitic fluid bacterial culture
elevated ascitic fluid absolute PMN count
abdominal paracentesis

50
Q

What are the three most common isolates of SBP?

A

E.coli, K. pneumoniae, S. pneumonia

51
Q

How do you tx SBP?

A

Cefotaxime 2gm IV q8h

Ceftriaxone 1gm Q24h

52
Q

Could you consider Flouroquinolone in pts w/o prior quinolone exposure?

A

Yes

53
Q

Should you give albumin infusions with antimicrobial therapy for SBP?

A

Yes

54
Q

how do you prophylax SBP for pts with previous episodes?

A

Norfloxacin 400mg QD
Trimethoprim-Sulfamethoxazole DS QD
Ciprofloxacin 750mg PO qwk

55
Q

What is Hepatic encephalopathy?

A

spectrum of neurological to psychosocial symptoms in the setting of liver disease
- alterend level of consciouness, intellectual functioninong and behavior
-altered skeletal muscle and motor skills
Elevated ammonia level

56
Q

What is the tx for HE?

A 
avoid Benzos and narcotic analgesics (consider reversal with flumazenil/naloxone
limit daily protein
lactulose
neomycin or metronidazole
Rifaximin
Zinc
57
Q

How does lactulose work?

A

It is a nonabsorbable disaccharide that undergoes fermenation by gut flora and produces organic acids which lower colonic pH; the acidification of colon lowers ammonia levels in the blood by reducing protein degradation and ammonia absorption

58
Q

What is the dose of Lactulose for management of HE?

A

20g/30mL PO TID, titrate to 3-4 bowel movements per day

59
Q

Can you give Lactulose as an enema?

A

300mL mixed with 700mL water/saline

60
Q

What are some adverse effects of Lactulose?

A

Diarrhea, Cramping, Flatulence, Dyspepsia

61
Q

Can you use Neomycin or Metronidazole for HE?

A

Yes

62
Q

What does neomycin do to bacteria?

A

kills them; inhibits activity of urease-producing bacteria

63
Q

what is the Dose of neomycin for NE acute episodes and maintenance?

A

1g PO TID up to 6g daily for acute epidodes

1-2 g PO daily for maintenance

64
Q

when taking Neomycin what should you monitor for?

A

aminoglycoside so monitor renal function, ototoxicity and nephrotoxixicty with chronic use.

65
Q

Can you use Neomycin with lactulose?

A

Yes

66
Q

Can Metronidazole be used for HE? Why?

A

Yes; dec ammonia production by gut flora

67
Q

What is the dose of metronidazole for HE?

A

250mg PO q6-12 hours

68
Q

What must you be careful with when dosing metronidazole?

A

Neurotoxicity (peripheral neuropathy) with chronic use due to impaired hepatic clearance

69
Q

Can Rifaximin be used for HE? What is the MoA for HE?

A

Yes; dec urease producing bacteria in the GI tract; <1% absorbed after oral administration

70
Q

What is the prophylaxis dose of Rifaximin for HE?

A

550mg PO BID

71
Q

What is the tx dose of Rifaximin for HE?

A

400mg PO TID

72
Q

What is the efficacy of Rifaximin when compared to Neomycin?

A

Similar

73
Q

What are some ADRs of Rifaximin?

A

HA, Abdominal pain, constipation, N/V

74
Q

Can Zinc be used for HE?

A

Yes; cofactor of urea cycle enzyme

75
Q

Can you send pts home on zinc and can it be used as monotherapy?

A

Yes, but no not monotherpay, must be on lactulose and an antibiotic

76
Q

What is the dose of zinc for HE?

A

500mg daily can inc urea formation and lower ammonia levels

77
Q

Can renal failure happen in pts with liver disease? How?

A

Yes, liver cirrhosis that leads to vasoconstriction in renal vasculature

78
Q

What is the difference between type 1 and type 2 hepatorenal syndrome

A

Type 1 is rapidly progessive dec in renal function

Type 2 is steady moderate impairment in renal function

79
Q

How do you manage hepatorenal syndrome?

A 
avoid all nephrotoxic drugs
avoid overaggressive diuretic use
hemodialysis
albumin infusions
midodrine combined with octreotide
expedited referral for liver transplantation
80
Q

Impaired drug metabolism clinially significant only in severe liver disease with a Child-Pugh class of __

A

C

81
Q

Which phase of metabolism is effected more by liver damage?

A

Phase 1 (oxidation)

82
Q

Clearance of _____ extraction drugs is decreased in patients with chronic liver disease. So can you predict dosage reduction?

A

High; No you still cannot predict due to highly variable degree of hepatic blood flow reduction

83
Q

There are three categories of drug extraction, what are they?

A

High (>60%)
Intermediate (30-60)
Low (<30%)

84
Q

What are some high extraction drugs?

A

morphine, sertraline, fluvastatin, lovastatin, sumatriptan, labetalol, metoprolol, midazolam

85
Q

Do we need a dosage reduction for renally eliminated drugs?

A

Yes

86
Q

The volume of distribution of _______ drugs may be increased in patients with _____ and ______.

A

Hydrophilic
ascites
edema

87
Q

If the drug causes the following things you have to consider dose adjusting in liver disease:

A 
High extraction ratio drugs
Inc Na and water retention
Drugs that precipitate HE
Drugs that inc risk of ADRs
Highly protein bound drugs
APAP

Therapeutics IV Final Subjects (10 decks)

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