Flashcards in Cirrhosis and its Complications Deck (95):
what is the most common complication of cirrhosis?
most common cause of ascites?
most common physical exam findings for ascites?
flank dullness and shifting dullness
what is the first physical exam finding for ascites?
if pt has ascites and chronic liver disease what are clues that tell you this?
Chronic liver disease
-palmar erythema (very red palms)
-jaundice (I.e. sclera icterus)
NEW cause of ascites requires what labs?
-CBC, CMP, LFTs, Urea
-ascitic fluid analysis
what should you calculate for any cause of ascites?
SAAG (serum albumin acidic gradient)
what imaging should be done for ascites?
how do you get the fluid out to analyze it in ascites?
routine tests for ascitic fluid?
total protein, albumin, cell count
a protein <2.5g/dL in the ascitic fluid is associated with what?
portal HTN and hypoalbuminemia
a protein >2.5g/dL in the ascitic fluid is associated with what?
TB, malignancy, pancreatitis, myxedema
what is SAAG?
serum albumin acidic gradient
how do you calculate SAAG?
SAAG = serum albumin - ascites albumin
what is a high SAAG? what does it indicate?
SAAG >1.1 g/dL
-indicates portal HTN and suggests a non-peritoneal cause of ascites
non-peritoneal causes of ascites?
may have clot in portal vein (want to keep pressure <10mmHg)
how many grades of ascites?
what is Grade I of ascites and its treatment?
Grade I = only detectable by USS
Tx: salt restriction
what is Grade II of ascites and its treatment?
Grade II = moderate symmetrical enlargement of abdomen - shifting dullness
Tx: salt restriction + diuretics
what Grade of ascites do you see a shifting dullness?
what is Grade III of ascites and treatment?
Grade III - marked abdominal enlargement (hard as a rock) - transmitted thrill
Tx: large volume paracentesis + salt restriction + diuretics
what Grade of ascites do you see a transmitted thrill?
how can Grade II ascites pts be treated?
as outpatients unless there are other complications of cirrhosis
is renal sodium impaired in Grade II ascites?
renal sodium is not severely impaired, but excretion is low compared to intake
aim for what when treating Grade II ascites?
aim for negative sodium balance
when is fluid restriction required for tx of Grade II ascites?
only in those with dilution hyponatremia (Na <125)
normal sodium level?
in pts with cirrhosis, renal sodium is due to what?
renal sodium retention is d/t increased proximal and distal tubular sodium reabsorption rather than a decrease of filtered sodium
medications for Grade II ascites tx?
Diuretics - aldosterone antagonists (Spironolactone)
after 1st episode of Grade II ascites, what med do you start the pt on?
Spironolactone 100mg/day and increase 100mg/day stepwise every 7 days to max dose of 400mg/day
when would you add Furosemide to a Grade II ascites pts tx?
if no response to spironolactone (reduction of body weight < 2kg/week) or if develop hyperkalemia (from the spironolactone)
why is Spironolactone first choice med tx for ascites?
b/c activates RAAS to get rid of the fluid (inhibits aldosterone)
ascites pts have increased serum aldosterone d/t activation of RAAS
what is the max recommended weight loss for pt with Grade II ascites?
Max recommended weight loss should be 0.5kg/day in patients without edema or 1kg/day if have edema
when are diuretics are C/I in ascites?
if overt hepatic encephalopathy
-diuretics cause hypovolemia and hypovolemia worsens the hepatic encephalopathy (more build up on ammonia)
when do you D/C diuretics for ascites?
if severe hyponatremia (Na <120), renal failure, worsening encephalopathy or incapacitating muscle cramps
when should Furosemide be stopped for tx of ascites?
if hypokalemia (K < 3)
Grade III ascites management
Large Volume Paracentesis (LVP) + Albumin
LVP + Albumin is safer than diuretics terms of what?
in terms of hyponatremia, renal impairment, encephalopathy
LVP reduces what? but can cause what?
Reduces effective blood volume HOWEVER this can cause post-paracentesis circulatory dysfunction
the post-paracentesis circulatory dysfunction that can occur with LVP can lead to what?
rapid re-accumulation of ascites
what can increase in pts with circulatory dysfunction after LVP?
to prevent post-paracentesis circulatory dysfunction with LVP, what do you infuse?
infuse ALBUMIN 6-8g/Liter of fluid removed
resume what meds post LVP?
resume diuretics post LVP (if pt is doing ok)
do cirrhotic pts have a lot of hemorrhagic complications with LVP?
if pt has an abdominal scar (I.e. from hernia repair), where do you do the paracentesis?
DO NOT DO PARACENTESIS ON SAME SIDE AS ABD SCAR B/C ADHESIONS CAN ADHERE TO ABDOMINAL WALL
DO PARACENTESIS ON OPPOSITE SIDE!!!
when is TIPS indicated for ascites?
if paracentesis is not effective
who is TIPS for?
For pts with refractory ascites needing frequent paracentesis (>3/month) who are not candidates for liver transplantation
what does TIPS do?
decreases vascular resistance of the liver by creating a shunt b/w the higher-pressure portal vein and the lower-pressure hepatic vein -> DECREASING PORTAL VENOUS PRESSURE
THUS REDUCES PRODUCTION OF ASCITES
bad side effect of TIPS?
Complications of ascites
Umbilical hernia (d/t pressure behind belly button)
-Pleural effusion, Right > Left
what sided pleural effusion is a common complication of ascites?
right sided pleural effusion
all pts with ascites are at risk for what?
SBP (spontaneous bacterial peritonitis)
what is SBP?
infection of the peritoneal fluid
Clinical presentation of SBP
abd pain, tenderness, emesis, fever (pt appears sick)
pt may be asymptomatic
at what ascitic neutrophil count do you assume pt has SBP?
Ascitic neutrophils count >250/mm3
what is culture-negative SBP?
fluid cell count >250 but culture negative
what is Bacterascites for SBP?
fluid cell count <250 but positive cultures
-possibly early SBP
if ascitic fluid cx is negative what do you do?
repeat and if cell count remains >250 then treat (with abx - Ceftriaxone)
if ascitic fluid cx is <250, what do you do?
draw again to confirm ascetic neutrophils count is low (but better to treat than not treat)
most common pathogens for SBP?
gram negatives -> e.coli
gram positives -> streptococcus
Tx of choice for SBP?
2nd line abx for tx of SBP?
amoxicillin/clavulanic acid and fluoroquinolones
when do you avoid fluroquinolones for tx of SBP?
if the pt is on them for SBP ppx
what do you repeat after treatment of SBP?
repeat paracentesis to ensure ascetic neutrophil count <250/mm3 and sterile cultures after treatment
if SBP pt is worsening after 48hrs of abx tx, what may it be?
may be due to abx resistance or secondary bacterial peritonitis
what is hepatorenal syndrome?
occurrence of renal failure in patient with advanced liver disease in absence of identifiable cause of renal failure
what do you need to r/o before dx hepatorenal syndrome (HRS)?
-Parenchymal renal disease
-Nephrotoxins (ex: morphine, Lasix -> these ruin the kidney)
consider parenchymal renal disease (CKD) when?
if significant proteinuria or micro-hematuria, renal U/S abnormalities
criteria for dx of HRS in cirrhosis?
Cirrhosis with ascites
-serum Cr >1.5mg/dl (133 mol/L)
Absence of shock
No current or recent tx with nephrotoxic drugs
Absence of shock criteria for dx of HRS in cirrhosis is what?
absence of hypovolemia by no sustained improvement of renal function (Cr <133) following at least 2 days of diuretic withdrawal, and volume expansion with albumin
No current or recent tx w/nephrotoxic drugs for dx of HRS in cirrhosis is what?
absence of parenchymal renal disease as defined by proteinuria <0.5 g/day, no microhaematuria (<50 red cells/high powered filed), and normal renal ultrasonography
cirrhosis with ascites for dx of HRS in cirrhosis is what?
serum Cr >1.5mg/dl (133 mol/L)
what are the 2 types of HRS?
-rapid progressive impairment in renal function (over 100% increase in creatinine in less than 2 weeks) í happens faster than HRS2
-stable and less progressive impairment in renal function
what has the highest risk of developing HRS? means what?
development of infections (SBP) -> means need to dx and treat to improve survival
where should pts with HRS be monitored?
in the ICU
monitor what in HRS?
urine output, fluid balance, ideally CVP (in the ICU)
what do you screen for in HRS management?
-blood and ascetic culture, ppx abx if no active infection
what meds to use for HRS management?
-improves renal fxn in Type 1 HRS
what replacement therapy should be done for HRS management?
renal replacement therapy (hemodialysis)
-hyperkalemia, volume, metabolic acidosis
___ transplant should be done ASAP for HRS
what meds should be stopped if pt has HRS?
what is hepatic encephalopathy characterized as?
personality changes, intellectual impairment, and a depressed level of consciousness
why does ammonia build up in liver failure?
b/c have less hepatocytes able to detoxify the ammonia
hepatic encephalopathy precipitating factors
Constipation - not pooping out ammonia
Infections - bacteria may increase ammonia load
GI Bleeding - increase in nitrogenous load in the GIT and therefore increased ammonia level
Shunts - increases HE (ex: TIPS procedure)
Renal Failure - decreased clearance of urea, ammonia, and other nitrogenous compounds
Medications - benzo's, antidepressants, antipsychotics (all act on CNS)
Diuretics - decrease K levels and alkalosis making it more difficult to convert ammonia to ammonium -> build up of ammonia
what is the first thing to do when managing hepatic encephalopathy?
that there are no other causes for the encephalopathy
-obtain head CT, r/o bleeds or lesions
-EEG to r/o seizure activity
what level should you get for hepatic encephalopathy?
ammonia level - get once, don't need to follow it
#1 medication for treatment of hepatic encephalopathy?
Lactulose - has laxative effect to remove nitrogenous wastes and bacteria
Lactulose dose to start
20-60ml 3x/day, titrated to achieve 2-4 soft stools/day without diarrhea
what must you warn pt on Lactulose?
Warn the patient to not overdose as can cause hypovolemia, thus worsening the encephalopathy
-when hypovolemic, also more acidotic, thus body makes more ammonia
how can Lactulose be administered?
NGT or enema in hospitalized pts unable to take themselves
what are the 2nd line agents to treat hepatic encephalopathy?
Abx - Neomycin, Flagyl, PO Vanco, Rifaximin
-used after failure of Lactulose
when are abx used to treat hepatic encephalopathy?
after failure of Lactulose
what else can be used for tx of hepatic encephalopathy besides Lactulose and Abx?
Probiotics - make colon empty quicker (have a laxative effect)
Fermentable fibers - help modulate acidity of gut so the bacteria that make ammonia can't go to the liver
if pt has ascites and Portal HTN what are clues that tell you this?
-splenomegaly and large collateral veins (caput medusa)