Treatment of Liver disease

Question 1

The treatment for Pruritis is:

Answer 1

Anion Exchange Resins e.g. colestyramine, colestipol

Councelling, Antihistamines, Ursodeoxycholic acid, Topical therapies, rifampicin and opioid antagonists

Question 2

How do Anion Exchange Resins work?

Answer 2

They bind the bile acids and prevent reabsorption from the gut into the blood. The side effects are GI (constipation, diarrhoea etc) and fat and vitamin malabsorption.

Question 3

The other treatment of pruritis is Councelling:

Answer 3

Talk about the possible side effects to increase adherance
Take interacting drugs 1 hour before or 4 hours after Colestyramine,
Benefits may take up to one week to become apparent

Question 4

Antihistamine treatment:

Answer 4

Sedating properties may be useful if pruritis affects sleep

Question 5

Ursodeoxycholic acid used to treat what type of liver disease, and is the product of what:

Answer 5

Used to treat Cholestatic disease, and is the product of bile salt bacterial metabolism.

Question 6

Rifampicin is an:

Answer 6

Antibiotic used here to inhibit hepatocyte uptake of bile salts to reduce reabsorption rather than the antiobiotic properties.

Question 7

Opioid antagonists are used because:

Answer 7

Itching is thought to be due to increased endogenous opiate tone.

Question 8

The topical therapies are

Answer 8

Calamine lotion, menthol aqueous cream but evidence is less clear

Question 9

The treatment of Ascites are aimed to

Answer 9

mobilise intra-abdominal fluid

Question 10

What are the simple measures to treat Ascites

Answer 10

Reduce sodium intake

Fluid restriction

Question 11

Moderate to severe Ascites require what type of treatment:

Answer 11

Diuresis (increased urine production), or paracentisis: suck fluid out using a syringe and needle
or TIPS

Question 12

What are the possible Diuretic treatment:

Answer 12

Spironolactone is the 1st line treatment. It works by blocking the reabsorption in the kidney tubules
The dose ranges between 50-400mg daily, and should be titrated slowly
If severe, Furosemide may be added
Care should be taken to avoid excessive diuresis

Question 13

What are the facts about Paracentisis?

Answer 13

It is used in refractory ascites (don’t respond to other treatment) and is combined with albumin administration. Repeated every 2-4 weeks

Question 14

What is the disadvantage about Paracentisis?

Answer 14

It does not affect the mechanism responsible for fluid accumulation

Question 15

What is TIPS?

Answer 15

Transjugular intraheatic portosystemic shunt. Putting a stent into the shunt between the hepatic portal vein and systemic circulation

Question 16

What are the symptoms of Enceohalopathy?

Answer 16

Lack of awareness, altered mental state, disorientation, coma

Question 17

What are the causes of Encephalopathy?

Answer 17

Complex: Portosystemic shunting (a bypass of the liver by the systemi circulation), metabolic dysfuction, alteration of the BBB.

Question 18

What precipitates the causes of Encephalopathy?

Answer 18

GI bleeding, SPB (spontaneous bacterial peritontitis) which occurs in people with portal hypertension, contipation and drugs
*these should be removed if present

Question 19

What are the treatment options for Encephalopathy?

Answer 19

The condition is reversible,
treatment includes LACTULOSE which acidifies colonic contents, leading to ionisation of nitrogenous products and therefore reduction in absorption
and ANTIBIOTICS like Metronidazole which reduces ammonia production by the GI bacteria

Question 20

What are the treatment for Clotting abnormalities?

Answer 20

IV phytomenadione (vit K) 10mg for 3 days. This is not significant in patients with significant disease.
Patients should also avoid NSAIDs, aspirin and anticoagulants.

Question 21

The treatment of Varices which is the shunting of the portal blood to the systemic circulation to try to reduce portal hypertension, where pre-existing vessels dilate and there is active angiogenesis (new vessels formation):

Answer 21

The initial treatment is to stop immediate bleeding, treat hypovolaemic shock and the aim is to prevent recurrent bleeding.

Question 22

What is the immediate treatment?

Answer 22

Terlipressin which is a vasopressin analogue and a systemic vasoconstrictor infused for 2-5 days.

Question 23

What is the prevention treatment?

Answer 23

Band ligation- placing tiny elastic bands around the varices to prevent them from bleeding
or Long term non-selective Beta blockers lie propanolol. These decrease the Portal HYpertension by causing Splanchic vasoconstriction and decreasing the portal blood flow.