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PT3 GI and DERM > liver therapeutics > Flashcards

liver therapeutics Flashcards

1
Q

labs indicative of cirrhosis

A
  • decreased platelets
  • elevated pt/INR
  • elevated bilirubin
  • decreased albumin
  • normal or elevated AST/ALT
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2
Q

clinically significant portal HTN value

A

> = 10 mmHg

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3
Q

portal HTN greater than 12 puts you at risk for what

A

gastroesophageal hemorrhage

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4
Q

characteristics of compensated cirrhosis

A
  • mild to clinically significant portal HTN

- varices

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5
Q

characteristics of decompensated cirrhosis

A
  • ascites
  • variceal hemorrhage
  • hepatic encephalopathy
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6
Q

characteristics of late decompesated cirrhosis

A
  • refractory ascites
  • recurrent variceal hemorrhage
  • recurrent hepatic encephalopathy
  • hepatorenal syndrome
  • jaundice
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7
Q

child-pugh grade scale

A

Grade A <7
Grade B 7-9
Grade C 10-15

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8
Q

child-pugh point system

A

from 1-3

2 point criteria:
bilirubin = 2-3
albumin = 2.8-3.5 (lower is worse)
mild ascites
HE grade 1 and 2
PT wave 4-6 seconds
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9
Q

important counseling points for cirrhosis

A
  • stop drinking alcohol
  • lose weight if NASH is present
  • discontinue NSAIDs
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10
Q

most common complication of cirrhosis

A

ascites

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11
Q

goals of ascites treatment

A
  • control ascites
  • prevent dyspnea
  • prevent abdominal pain and distention
  • prevent SBP and hepatorenal syndrome
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12
Q

treatment for ascites

A
  • spironolactone and furosemide (together is best)
  • if they can only handle one spironolactone is better
  • paracentesis
  • sodium restriction
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13
Q

ratio for spironolatone/furosemide dosing

A

100:40 mg up to 400/160

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14
Q

which diuretic do you avoid in ascites

A

HCTZ

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15
Q

paracentesis

A

drawing fluid straight out of abdomen for ascites

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16
Q

what is required to do if over 5L of ascitic fluid is removed

A

6-8g/L of albumin

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17
Q

refractory ascites

A

fluid overload is unresponsive to Na restriction and diuretics or occurs rapidly after parcentesis

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18
Q

treatment for refractory ascites

A
  • add midodrine TID to diuretics
  • liver transplantation
  • TIPS
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19
Q

TIPS

A

stent to help flow through the liver

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20
Q

important lab value to consider when using spironolactone and furosemide

A

potassium

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21
Q

spontaneous bacterial peritonitis(SBP) incidence

A

10-20%

recurrence up to 70%

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22
Q

risk factors for SBP

A
  • variceal hemorrhage
  • prior SBP
  • ascitic fluid protein conc. < 1-1.5
  • PPI use
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23
Q

presentation of SBP

A
  • fever
  • abdominal pain
  • encephalopathy
  • renal failure
  • acidosis
  • leukocytosis
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24
Q

SBP diagnosis

A
  • ascitic fluid PMN >250

- ascitic fluid culture

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25
antibiotics for SBP treatment
cefotaxime | ceftriaxone
26
albumin indication when treating SBP criteria
any one of these: SCr >1 BUN >30 billirubin >4
27
albumin dosing for SBP
1.5g/kg on day one, 1g/kg on day 3
28
antibiotic treatment duration for SBP
5 days
29
SBP long-term antibiotic prophylaxis drugs
bactrim DS once daily | cipro once daily
30
how do esophageal varices form
- formation of new vessels due to increased portal pressure | - dilation of preexisting vessels
31
drugs for acute management of variceal hemorrhage
- octreotide for 2-5 days | - ceftriaxone for up to 7 days
32
octreotide MoA
inhibits release of vasodilator hormones
33
octreotide adverse effects
bradycardia HTN arrhythmia abdominal pain
34
alternative to octreotide in variceal hemorrhage
vasopression, but its not used as much due to ADRs
35
procedures for acute variceal hemorrhage
- endoscopy within 12 hours of presentation - blood transfusion for Hgb <7 - EVL (rubber bands) - TIPS
36
when to do primary prophylaxis of variceal hemorrhage
- medium/large varices - small varices that are high risk of hemorrhage - decompensated patient w/small varices
37
secondary prophylaxis of variceal hemorrhage
after it occurs | use beta blocker (except carvedilol) and EVL
38
prophylaxis for variceal hemorrhage
nonselective beta blocker or EVL
39
how do beta blockers prevent variceal hemorrhage
- beta-1 reduces portal flow via decreased CO - beta-2 reduces portal flow via vasoconstriction - alpha-1 decreases vascular resistance via vasodilation
40
beta blocker treatment goal in prophylaxis
HR 55-60
41
beta blocker dosing strategy in ascites
always titrate up every 2-3 days
42
propranolol max doses in ascites prophylaxis
320 if no ascites | 160 if ascites present
43
nadolol max doses in ascites prophylaxis
160 if no ascites | 80 if ascites
44
carvedilol max dose in ascites prophylaxis
12.5 mg
45
beta blocker metabolized by liver
propranolol
46
beta blocker excreted unchanged in urine
nadolol
47
are beta blockers contraindicated in patients with refractory ascites
no, but avoid higher doses
48
hepatic encephalopathy classification
- minimal to grade 1 = covert | - grade 2 - 4 = overt
49
covert HE symptoms
- abnormal psychological test - trivial lack of awareness - euphoria - shortened attention span - altered sleep
50
overt HE symptoms
- lethargic - disorientation for time - personality change - confusion - asterixis
51
asterixis
involuntary flapping of hands
52
recurrent HE classification
episodes occur with a time interval less than 6 months
53
persistent HE classification
patter of behavioral changes that are always present
54
the substance that is commonly increased in HE
ammonia
55
HE risk factors
- infections - GI bleeding - electrolyte abnormalities - constipation - diuretic overdose
56
when to treat HE
- always for overt symptoms | - if covert affect things like driving or work performance
57
first line HE treatment
- lactulose 30-45 mL ever 1-2 hours until bowel movements | - adjust until 2-3 movements a day
58
lactulose MoA
decreases pH to convert ammonia to ammonium
59
alternative treatments for HE
Rifaximin | Neomycin (not preferred due to ototoxicity and nephrotoxicity)
60
rifaximin dosing
550 bid
61
neomycin dosing
1000 mg q6h for up to 6 days then 1-2 g daily

PT3 GI and DERM (8 decks)

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