Cirrhosis

Question 1

What is the gold standard for cirrhosis diagnosis?

Answer 1

Liver biopsy

Question 2

Is cirrhosis a disease?

Answer 2

No, it is a final common pathway of liver damage

Question 3

What does cirrhosis result from?

Answer 3

fibrotic changes w/in the hepatic sinusoids and results in changes in the levels of vasodilatory and vasoconstrictor mediators and in increase in blood flow to the splanchnic vasculature

Question 4

What do the grades rate in cirrhosis?

Answer 4

Degree of liver inflammation

Question 5

What do the stages rate in cirrhosis?

Answer 5

Degree of fibrosis

Question 6

What are the effects of portal HTN?

Answer 6

Esophageal varices (hematemesis)
Melena (gastrophy)
Splenomegaly
Dilated abdominal veins (caput medusa)
Ascites (more advanced)
Rectal varices (hemorrhoids)

Question 7

What are the effects of liver cell failures?

Answer 7

Coma
Fetor hepaticus (breath smells like a freshly opened corpse)
Spider nevi
Gynecomastia
Jaundice
Ascites
Loss of sexual hair
Testicular atrophy
Liver "flap" (coarse hand tremor)
Bleeding tendency (decreased prothrombin)
Anemia (macrocytic, iron deliciency)
Ankle edema

Question 8

What is compensated cirrhosis?

Answer 8

Further substaged by presence of mild mortal HTN or clinically significant portal HTN
Median survival: >12 years

Question 9

What is decompensated cirrhosis?

Answer 9

Presence of ascites, variceal hemorrhage, and/or hepatic encephalopathy
Median survival: 2 years

Question 10

What are the potential complications of cirrhosis?

Answer 10

Portal HTN
VAriceal bleeding
Ascites
Spontaneous bacterial peritonitis
Hepatic encephalopathy
Hepatorenal syndrome
Coagulation disorders

Question 11

What are coagulation disorders

Answer 11

Both pro- and anticoagulant proteins are reduced with a tendency toward hypocoagulability in earlier stages of cirrhosis
Bleeding
Portal vein thrombosis

Question 12

What are general supportive care for cirrhosis?

Answer 12

Alcohol abstinence is KEY
Vaccinations: HAV, HBV, flu and pneumococcal
TLC (reduce obesity with diet and exercise, smoking cessation, dc coffee)
Statins - evidence they may decrease portal HTN and incidence of HCC

Question 13

What is portal HTN?

Answer 13

Increased resistance to blood flow in the liver ultimately resulting in the formation of collateral blood vessels (varices) in an attempt to reduce resistance

Question 14

When do we prophylax for varices?

Answer 14

ALL patients with medium to large varices

Question 15

What is primary prophylaxis for varices?

Answer 15

Non-selective Beta-blockers

Propranolol - is most common

Question 16

What do we do if the pt cannot take beta-blockers for prophylaxis of varices?

Answer 16

Endoscopic varcieal ligation

Question 17

What is the MOA of beta-blockers in variceal bleeds?

Answer 17

Decrease portal venous inflow through B1-adrenergic blockade (decreased CO) and B2-adrenergic blockade (decreased splanchnic blood flow)

Question 18

What is the treatment for acute variceal bleeding?

Answer 18

Octreotide + abx + endoscopic ligation/sclerotherapy

Question 19

What is octreotide MOA?

Answer 19

Selective splanchnic vasoconstriction

Question 20

What abx are used in acute variceal bleeding?

Answer 20

Cipro

Ceftriaxone

Question 21

Why are abx used in acute variceal bleeds?

Answer 21

Reduces short term mortality

Question 22

What are treatment options for refractory acute variceal bleeding?

Answer 22

Balloon tamponade

TIPS (transjugular intrahepatic portosystemic shunt)

Question 23

What is the duration of octreotide in variceal bleeds?

Answer 23

2-5 days

Question 24

What is the dosing of cipro for acute variceal bleeding?

Answer 24

400 mg IV or po q12h x 5-7 days or until discharge

Question 25

What is the dosing of Ceftriaxone in acute variceal bleeding?

Answer 25

1g IV QD x 5-7 days if FQ resistance is suspected

Question 26

What is the treatment of refractory acute variceal bleeding?

Answer 26

``` Balloon tamponade (temporary) TIPS ```

Question 27

What is secondary prevention of bleeding that is required?

Answer 27

Treatment: propranolol titrated to HR 55-65 | Endoscopic ligation

Question 28

What is the cause of ascites in variceal bleeding?

Answer 28

Portal HTN and low albumin

Question 29

What are the treatment goals of ascites?

Answer 29

Control ascites Prevent SBP and hepatorenal syndrome Prevent or relieve ascites-related symptoms

Question 30

What is the dietary restriction for ascites?

Answer 30

Na restriction (<2,000mg/d) and diuretics

Question 31

What diuretics are used in ascites?

Answer 31

Furosemide 40mg and Spironolactone 100mg in single am dose | Increase by doubling dose

Question 32

What is the max furosemide dose in ascites?

Answer 32

160mg/d

Question 33

What is the max spironolactone dose in ascites?

Answer 33

400mg/d

Question 34

What do we monitor with lasix/spironolactone use?

Answer 34

Na K SCr

Question 35

How do we treat refractory ascites?

Answer 35

Midodrine (7.5 mg po TID) + diuretic therapy Paracentesis Liver transplant

Question 36

What classes of medications may be harmful to pts with ascites?

Answer 36

ACE/ARBs | NSAIDs (bleeding)

Question 37

What is spontaneous bacterial peritonitis?

Answer 37

Infection of previously sterile ascetic fluid w/o apparent intra-abdominal source probably d/t seeding of the ascetic fluid from an episode of bacteremia

Question 38

What are the common causes of SBP?

Answer 38

Enteric G- pathogens | Single bacterial species

Question 39

What do we collect prior to initiating SBP empiric therapy?

Answer 39

Ascetic fluid

Question 40

When do we give empiric abx for SBP?

Answer 40

PMNs >/= 250

Question 41

When do we treat a patient empirically if their PMNs = 250?

Answer 41

Patient has s/sx of infection

Question 42

What medications can be given for empiric therapy of SBP?

Answer 42

3rd gen ceph (cefotaxime/ceftriaxone) IV | Oral FQ

Question 43

Which medications do we avoid in empiric therapy of SBP?

Answer 43

AG - high risk of renal failure in cirrhotic patients with SBP

Question 44

What is the duration of therapy in SBP

Answer 44

5-10 days

Question 45

What can we give to prevent hepatorenal syndrome?

Answer 45

Albumin

Question 46

What is primary prophylaxis of SBP?

Answer 46

Norfloxacin/Bactrim for 7 days in patients with GI bleeding

Question 47

What is secondary prophylaxis of SBP?

Answer 47

Norfloxacin/Bactrim dosed each day indefinitely (if ascites)

Question 48

What causes hepatic encephalopathy?

Answer 48

Impaired brain function associated with hepatic insufficiency Accumulation of nitrogenous substances (mainly NH3) from the gut Activation of GABA by endogenous benzodiazepine-like substances

Question 49

What are the ways to classify hepatic encephalopathy?

Answer 49

West Haven Criteria and Glasgow Coma Scale