Portal HTN, Variceal Bleeding and SBP

Question 1

patho

Answer 1

inc cirrhosis
dec BF to liver
portal HTN (inc BP in PV compared to HP)
BF backs up from liver to splanchnic circulation
portal Hypertension
collateral vessels form (varices)
dilate and rupture
variceal bleeding

Question 2

variceal bleeding/P. HTN AE

Answer 2

1/3 of cirrhotic-related deaths

1/4-1/2 cirrhotic patients will experience this

Question 3

VB goal

Answer 3

prevent it!

Question 4

when do we treat for VB

Answer 4

only tx when we have proven that varices have formed

Question 5

VB Dx

Answer 5

upper endoscopy (EGD)

Question 6

patient is diagnosed with portal hypertension and variceal bleeding
what do we use to tx

Answer 6

non-selective beta blockers
propranolol 20-40mg po BID
Nadolol 20-40mg po QD
Carvedilol 3.125mg po BID
titrate up to resting HR of ~60bpm

Question 7

why do we use non-selective beta blockers in portal HTN and variceal bleeding risk?

Answer 7

• • | B1 = dec HR, dec CO, dec blood vol in splanchnic circulation, and therefore dec portal pressure
• • | B2 = decreases splanchnic dilation which decreases the formation of varices and bursting

Question 8

when do we dec/hold the dose of a non-selective beta blocker when treating portal HTN and variceal bleed risk?

Answer 8

hypotension (<90/60)
HR <60bpm
decompensated states (HRS w/ dec renal bloodflow)
refractory ascites (maxed diuretic and cant tolerate due to decreased blood pressure, frequent paracentesis, etc. dec fluid)
SBP ; sepsis where BP TANKS –> hold

Question 9

variceal bleeding

Answer 9

usually due to dec adherence to medications and decreased access to healthcare
consequence of portal HTN
1/3 of cirrhotic related deaths
occurs in 25-40% of cirrhotic patients

Question 10

variceal bleeding treatment

Hgb goal?

Answer 10

supportive (IV fluids, packed RBC, sup O2)
Hgb goal is ~8!
Octreotide 50mcg IV bolus then infusion
EVL (endoscopic variceal ligation) - do this while doing a EGD (upper endoscopy)

Question 11

patient has variceal bleeding and is given Octreotide bolus and infusion as well as an EVL via an EGD with no relief
what is the next option?
what medication is imoprtant to stop at this time if the patient was already on it for portal hypertension?

Answer 11

TIPS
transjugular intrahepatic portosystemic shunt

D/C betablocker

Question 12

patient has variceal bleeding and received octreotide and a EVL via EGD and the bleeding subsided. What should the patient also receive at this time?

Answer 12

SBP prophylaxis!!
ceftriaxone IV x7d
(3rd gen cephalosporin)

restart beta blocker, start low go slow

Question 13

when do we hold the dose of a beta blocker

Answer 13

BP <90/60
HR <60bpm
HRS
SBP
variceal bleeding ONLY if progresses to SBP as well as sepsis!!!

Question 14

octreotide moa for variceal bleeding

Answer 14

inhibits glucagon which vasoconstricts splanchnic circulation

Question 15

SBP definition

Answer 15

bacterial infection of ascitic fluid
e. coli
k. pneumoniae
s. aureus
s. pneumo
FREQUENT CAUSE OF DEATH

Question 16

SBP Dx

Answer 16

fever, malaise, inc WBC, pain +/- tenderness in abdomen
paracentesis tap –> take fluid and analyze it or bacteria and WBCs
if absolute polymorphonucleated (PMN) count >/=250/mm3
** also do cultures (just like if ascites) BUT BUT BUT! may be negative because patient should already be on SBP prophylaxis bc they have likely had portal hypertension and variceal bleeding prior to know which required SBP Prophylaxis

Question 17

cirrhosis causes _____

Answer 17

portal hypertension then ascites and variceal bleeding then SBP

Question 18

abdominal paracentesis is done for _______

Answer 18

ascites as well as to see if SBP is going on

Question 19

SBP ABX treatment

Answer 19

patient should be on 7day IV ceftriaxone prophylaxis already until cultures come back
EMPIRIC options: continue ceftriaxone
start cefotaxime
(cipro if allergy)
streamline ABX therapy within 48-72 hours of initiating prophylaxis
DIRECTED TX: IV amp if e. coli etc.

Question 20

SBP general tx

Answer 20

empiric then directed ABX

IV albumin

Question 21

when do we give IV albumin in SBP

what is the benefit?

Answer 21

give IV albumin 25% if

SCr >1
BUN>30
BILI>4

decreases mortality!

Question 22

IV albumin dose for SBP

Answer 22

1.5g/kg Day 1 ——-> 1g/kg Day 3