Liver Disease: Management of Cirrhosis Flashcards
Ascites defn
§ Accumulation of fluid in the peritoneal cavity.
§ Several contributing factors including:
–Splanchnic vasodilation
–Increased capillary filtration pressure
–Activation of the renin-angiotensin-aldosterone-system (RAAS)
–Decreased albumin
Lymphatic system is overwhelmed
Symptoms of Ascites
§ Abdominal distension
§ Shortness of breath
§ Weight gain
§ Early satiety
goals for ascites tx
§ Eliminate symptoms
§ Reduce the volume in fluid in abdomen, but need to very careful not to cause intravascular volume depletion
§ Prevent recurrence
treatment for Ascites approaches
§ Sodium and fluid restriction § Diuretics § Albumin § Invasive procedures: –Paracentesis –TIPS (Transjugular intrahepatic portosystemic shunt)
Diuretics (3)
Dont need to know dosing for exam
Furosemide:
§ Dose: 40 – 160 mg/day
§ Start 40 mg day, increase 20 –
40 mg/day up to 160 mg
Spironolactone: § Onset of action 2 – 5 days § Dose: 100 - 400 mg/day § Start 100 – 200 mg/day, increase every 5 – 7 days up to 400 mg Aldosterone antagonist Longer to work
Metolazone:
§ Dose: 2.5 – 10 mg/day
§ Start 2.5 mg day, increase up to
10 mg/day as tolerated
Titrate to response!
Measure abdominal girth
Urine output, what is taken in
Target a certain amount of loss per day
Diuretics monitoring for efficacy
Weight, abdominal girth, ins and outs
Roughly 500 ml/day or 0.5 kg/day
Urine output, what is taken in
Target a certain amount of loss per day
titrating dose based on that
Diuretics monitoring for toxicity
Electrolytes, serum creatinine, BUN, hypotension
furosemide, metolazone – uric acid, hyperglycemia, volume depletion
spironolactone – hyperkalemia, gynecomastia/mastalgia, muscle cramps
ascites non-pharm
rescit dietary Na+
restrict fluids to 1.5L/day
bedrest if severe or refractory
ascities parecentesis
flowchart
tap 3-4 L + nonpharm –> improvement = no med
no improvement –> spironolactone
improve –> continue spir
no improvement –? furosemide
improve –? continue spir + furos
no improvement –? metolazone
improve –? continue spir + furos + metolazone
if no improvement, continue 3 diuretics and perform weekly large vol paracentesis
if >5L is removed, infuse 6-8g/L albumin
consider TIPS
what is TIPS
transjugular intrahepatic portosystemic shunt
Metallic shunt connects portal vein t hepatic vein, bypasses the liver
Preventing backup and ascities
Spontaneous Bacterial Peritonitis (SBP)
§ Occurs in 10 – 25 % of patients with ascites § Infection of pre-existing ascitic fluid in peritoneal cavity § Pathogens: E. coli, enterococcus, S. pneumonia § Exact mechanism for inoculation unknown
SBP Treatment:
prevention?
§ Empiric antibiotics: 3rd generation cephalosporins (cefotaxime, ceftriaxone) § Adjust therapy based on culture results of ascites fluid.
Prevention:
§ Trimethoprim/sulfamethoxazole or ciprofloxacin
§ May need long term if previous SBP
Watch for aby resistance, reserve for highest risk pt
Esophageal Varices
what is it
§ Dilated and weakened blood vessels caused
by portal hypertension
§ Alternate routes of blood flow from the portal
to systemic circulation
§ Low pressure vessels handling high pressure
loads
§ Presence is correlated to disease severity
Portal HTN
Dilated blood vessels as pressure goes out to collateral channels
Dilation of rectal veins
Normally low pressure vessels that become engourged, can burst and blee
what are collaterals?
- Esophageal varices
- Umbilical vein to abdominal wall (caput medusa)
- Rectal veins (internal mhemorrhoids
Esophageal Varices
how is it diagnosed?
§ Diagnosed by endoscopy
§ About 20% mortality risk per episode
§ Risk of bleeding dependent on: severity
of liver disease, property of varix (size,
thickness of wall), previous history of
bleeding
§ Variceal bleeding can occur once portal
venous pressure exceeds 12 mmHg
(normal is around 4 mmHg)
