Module 7: Complication of Cirrhosis Flashcards
Dr. Covert EXAM VI
Which factors are used to classify the stage of liver disease when using Child-Pugh?
-determines the severity of liver disease
-used for considerations in drug dosing
-Tbili, PT (prothrombin time), Albumin, Ascites, Encephalopathy
A: 5-6 points
B: 7-9 points
C: 10-15 points (severe)
Model of End-stage Liver disease (MELD)
-assess the 1-year mortality and
-assess the position on the transplant list
score
10-19: 6% mortality
20-29: 19.6%
30-39: 52.6%
>40: 71:3%
Maddrey Discriminate Function
(just know what it is for)
-help to decide if steroids are needed in EtOH-related liver disease
asses PT and Tbili
-if >32 -> poor prognosis, use steroids
-Prednisolone 40 mg PO daily x 4 weeks, then 2-week taper
What causes fluid accumulation in the peritoneal cavity?
-activated RAAS system:
sodium and fluid retention (in the blood vessels)
-reduction in albumin
decreased oncotic pressure in the blood vessel -> fluid shifts to tissues
What is a Paracentesis?
-catheter instilled into the abdomen and the fluid is drained off
-some patients may have it acutely or chronically (depending on how quickly the fluid backs up)
In patients who undergo Paracentesis, what should be administered to them?
if a large volume of removal (>5L paracentesis)
6-8g of 25% (25g/100ml) albumin /L removed
if more than 10L paracentesis ->
60-80g of 25% albumin / L removed
-there are also 5% (5g/100ml) products -> but 25% is better bc we want more albumin to restore the oncotic pressure and 5% would need more volume which they have more than enough!
Which diuretics are used in Ascites management?
-Spironoalctone and furosemide
(ratio of 100 mg spironolactone: 40 mg furosemide)
-goal is to facilitate Na excretion, and maintain eukalemia
Explain the ratio between Spironolactone and furosemide
in ascites: spironolactone is ued as the diurtetic
whereas in HF patients it is used to mitigate the RAAS system
is furosemide not the stronger diuretic???
in patients with hyperkalemia use a higher dose of furosemide than spironolactone (since K sparing)
Which electrolytes should be restricted to cirrhosis patients with Ascites?
-Sodium (Na+) restricted: <2g/day
-fluid restricted: <1L/day, only if severe hyponatremia (<125 mmol/L)
Vaptans (tolvaptan, conivaptan) improve Na but not outcomes
ADR: hepatotoxicity -> so not often used
short-term (<30 day) use only
Why are Vaptans often not used in patients with Ascites?
-they are often hypotonic hypervolemic hyponatremia -> sodium and fluid restriction works best
-Vaptans provide aquaresis -> excretion of water without electrolytes
What causes Encephalopathy in patients with cirrhosis?
-accumulation of nitrogenous substances
-Hyperammonemia (bc the liver can’t eliminate it)
-cause CNS toxicity (altered mental status)
-treat only symptomatic patients
Who should be treated with Hepatic Encephalopathy prophylaxis?
-high-risk patients
-patients with a history of encephalopathy
How is hepatic Encephalopathy treated?
-Lactulose:
*MOA: traps ammonia from the blood to the gut (converts it to ammonium, charged), kills bacteria, and osmotically removes ammonia from the body with the stool
*titrate to 2-3 loose bowel movements per day, not to a dose
-Rifaximin
*adjunctive to Lactulose, avoid monotherapy
it has only 1 MOA, whereas Lactulose has 3
Esophageal varices
-varices are small blood vessels around the esophagus (where it connects to the stomach)
-they develop to to reduce pressure in severe portal hypertension -> blood flows through this vessels to relieve pressure
-these vessels are fragile and may burst (upper GI bleeding)
Who is indicated to receive therapy for Esophageal varices?
-varices > 5 mm - need endoscopy to assess
treat with medication or endoscopic variceal ligation (EVL)
-varices < 5mm + increased risk of bleeding
Child pugh B or C
-acute hemorrhage (variceal bleed)
patients vomit blood, hemodynamically unstable, anemic
