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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
Q

antibiotics for SBP treatment

A

cefotaxime

ceftriaxone

26
Q

albumin indication when treating SBP criteria

A

any one of these:

SCr >1
BUN >30
billirubin >4

27
Q

albumin dosing for SBP

A

1.5g/kg on day one, 1g/kg on day 3

28
Q

antibiotic treatment duration for SBP

29
Q

SBP long-term antibiotic prophylaxis drugs

A

bactrim DS once daily

cipro once daily

30
Q

how do esophageal varices form

A
  • formation of new vessels due to increased portal pressure

- dilation of preexisting vessels

31
Q

drugs for acute management of variceal hemorrhage

A
  • octreotide for 2-5 days

- ceftriaxone for up to 7 days

32
Q

octreotide MoA

A

inhibits release of vasodilator hormones

33
Q

octreotide adverse effects

A

bradycardia
HTN
arrhythmia
abdominal pain

34
Q

alternative to octreotide in variceal hemorrhage

A

vasopression, but its not used as much due to ADRs

35
Q

procedures for acute variceal hemorrhage

A
  • endoscopy within 12 hours of presentation
  • blood transfusion for Hgb <7
  • EVL (rubber bands)
  • TIPS
36
Q

when to do primary prophylaxis of variceal hemorrhage

A
  • medium/large varices
  • small varices that are high risk of hemorrhage
  • decompensated patient w/small varices
37
Q

secondary prophylaxis of variceal hemorrhage

A

after it occurs

use beta blocker (except carvedilol) and EVL

38
Q

prophylaxis for variceal hemorrhage

A

nonselective beta blocker or EVL

39
Q

how do beta blockers prevent variceal hemorrhage

A
  • beta-1 reduces portal flow via decreased CO
  • beta-2 reduces portal flow via vasoconstriction
  • alpha-1 decreases vascular resistance via vasodilation
40
Q

beta blocker treatment goal in prophylaxis

41
Q

beta blocker dosing strategy in ascites

A

always titrate up every 2-3 days

42
Q

propranolol max doses in ascites prophylaxis

A

320 if no ascites

160 if ascites present

43
Q

nadolol max doses in ascites prophylaxis

A

160 if no ascites

80 if ascites

44
Q

carvedilol max dose in ascites prophylaxis

45
Q

beta blocker metabolized by liver

A

propranolol

46
Q

beta blocker excreted unchanged in urine

47
Q

are beta blockers contraindicated in patients with refractory ascites

A

no, but avoid higher doses

48
Q

hepatic encephalopathy classification

A
  • minimal to grade 1 = covert

- grade 2 - 4 = overt

49
Q

covert HE symptoms

A
  • abnormal psychological test
  • trivial lack of awareness
  • euphoria
  • shortened attention span
  • altered sleep
50
Q

overt HE symptoms

A
  • lethargic
  • disorientation for time
  • personality change
  • confusion
  • asterixis
51
Q

asterixis

A

involuntary flapping of hands

52
Q

recurrent HE classification

A

episodes occur with a time interval less than 6 months

53
Q

persistent HE classification

A

patter of behavioral changes that are always present

54
Q

the substance that is commonly increased in HE

55
Q

HE risk factors

A
  • infections
  • GI bleeding
  • electrolyte abnormalities
  • constipation
  • diuretic overdose
56
Q

when to treat HE

A
  • always for overt symptoms

- if covert affect things like driving or work performance

57
Q

first line HE treatment

A
  • lactulose 30-45 mL ever 1-2 hours until bowel movements

- adjust until 2-3 movements a day

58
Q

lactulose MoA

A

decreases pH to convert ammonia to ammonium

59
Q

alternative treatments for HE

A

Rifaximin

Neomycin (not preferred due to ototoxicity and nephrotoxicity)

60
Q

rifaximin dosing

61
Q

neomycin dosing

A

1000 mg q6h for up to 6 days
then
1-2 g daily

PT3 GI and DERM (8 decks)

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