Cirrhosis and its Complications Flashcards Preview

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Flashcards in Cirrhosis and its Complications Deck (95):
1

what is the most common complication of cirrhosis?

ascites

2

most common cause of ascites?

cirrhosis

3

most common physical exam findings for ascites?

flank dullness and shifting dullness

4

what is the first physical exam finding for ascites?

flank dullness

5

if pt has ascites and chronic liver disease what are clues that tell you this?

Chronic liver disease
-palmar erythema (very red palms)
-spider nevi
-jaundice (I.e. sclera icterus)

6

NEW cause of ascites requires what labs?

-CBC, CMP, LFTs, Urea

-Abdominal US

-Dx Paracentesis

-ascitic fluid analysis

7

what should you calculate for any cause of ascites?

SAAG (serum albumin acidic gradient)

8

what imaging should be done for ascites?

abdominal US

9

how do you get the fluid out to analyze it in ascites?

a paracentesis

10

routine tests for ascitic fluid?

total protein, albumin, cell count

11

a protein <2.5g/dL in the ascitic fluid is associated with what?

portal HTN and hypoalbuminemia

12

a protein >2.5g/dL in the ascitic fluid is associated with what?

TB, malignancy, pancreatitis, myxedema

13

what is SAAG?

serum albumin acidic gradient

14

how do you calculate SAAG?

SAAG = serum albumin - ascites albumin

15

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

16

non-peritoneal causes of ascites?

may have clot in portal vein (want to keep pressure <10mmHg)

cirrhosis

17

how many grades of ascites?

3 grades

18

what is Grade I of ascites and its treatment?

Grade I = only detectable by USS

Tx: salt restriction

19

what is Grade II of ascites and its treatment?

Grade II = moderate symmetrical enlargement of abdomen - shifting dullness

Tx: salt restriction + diuretics

20

what Grade of ascites do you see a shifting dullness?

Grade II

21

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

22

what Grade of ascites do you see a transmitted thrill?

Grade III

23

how can Grade II ascites pts be treated?

as outpatients unless there are other complications of cirrhosis

24

is renal sodium impaired in Grade II ascites?

renal sodium is not severely impaired, but excretion is low compared to intake

25

aim for what when treating Grade II ascites?

aim for negative sodium balance

26

when is fluid restriction required for tx of Grade II ascites?

only in those with dilution hyponatremia (Na <125)

27

normal sodium level?

135-145

28

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

29

medications for Grade II ascites tx?

Diuretics - aldosterone antagonists (Spironolactone)

30

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

31

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)

32

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

33

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

34

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)

35

when do you D/C diuretics for ascites?

if severe hyponatremia (Na <120), renal failure, worsening encephalopathy or incapacitating muscle cramps

36

when should Furosemide be stopped for tx of ascites?

if hypokalemia (K < 3)

37

Grade III ascites management

Large Volume Paracentesis (LVP) + Albumin

38

LVP + Albumin is safer than diuretics terms of what?

in terms of hyponatremia, renal impairment, encephalopathy

39

LVP reduces what? but can cause what?

Reduces effective blood volume HOWEVER this can cause post-paracentesis circulatory dysfunction

40

the post-paracentesis circulatory dysfunction that can occur with LVP can lead to what?

rapid re-accumulation of ascites

41

what can increase in pts with circulatory dysfunction after LVP?

portal pressure

42

to prevent post-paracentesis circulatory dysfunction with LVP, what do you infuse?

infuse ALBUMIN 6-8g/Liter of fluid removed

43

resume what meds post LVP?

resume diuretics post LVP (if pt is doing ok)

44

do cirrhotic pts have a lot of hemorrhagic complications with LVP?

NO!!!

45

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!!!

46

when is TIPS indicated for ascites?

if paracentesis is not effective

47

who is TIPS for?

For pts with refractory ascites needing frequent paracentesis (>3/month) who are not candidates for liver transplantation

48

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

49

bad side effect of TIPS?

hepatic encephalopathy

50

Complications of ascites

Umbilical hernia (d/t pressure behind belly button)

Hydrothorax
-Pleural effusion, Right > Left

51

what sided pleural effusion is a common complication of ascites?

right sided pleural effusion

52

all pts with ascites are at risk for what?

SBP (spontaneous bacterial peritonitis)

53

what is SBP?

infection of the peritoneal fluid

54

Clinical presentation of SBP

abd pain, tenderness, emesis, fever (pt appears sick)

elevated WBC

pt may be asymptomatic

55

at what ascitic neutrophil count do you assume pt has SBP?

Ascitic neutrophils count >250/mm3

56

what is culture-negative SBP?

fluid cell count >250 but culture negative

57

what is Bacterascites for SBP?

fluid cell count <250 but positive cultures

-possibly early SBP

58

if ascitic fluid cx is negative what do you do?

repeat and if cell count remains >250 then treat (with abx - Ceftriaxone)

59

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)

60

most common pathogens for SBP?

gram negatives -> e.coli

gram positives -> streptococcus

61

Tx of choice for SBP?

Ceftriaxone IV

62

2nd line abx for tx of SBP?

amoxicillin/clavulanic acid and fluoroquinolones

63

when do you avoid fluroquinolones for tx of SBP?

if the pt is on them for SBP ppx

64

what do you repeat after treatment of SBP?

repeat paracentesis to ensure ascetic neutrophil count <250/mm3 and sterile cultures after treatment

65

if SBP pt is worsening after 48hrs of abx tx, what may it be?

may be due to abx resistance or secondary bacterial peritonitis

66

what is hepatorenal syndrome?

occurrence of renal failure in patient with advanced liver disease in absence of identifiable cause of renal failure

67

what do you need to r/o before dx hepatorenal syndrome (HRS)?

-Hypovolemia
-Shock
-Parenchymal renal disease
-Nephrotoxins (ex: morphine, Lasix -> these ruin the kidney)

68

consider parenchymal renal disease (CKD) when?

if significant proteinuria or micro-hematuria, renal U/S abnormalities

69

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

70

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

71

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

72

cirrhosis with ascites for dx of HRS in cirrhosis is what?

serum Cr >1.5mg/dl (133 mol/L)

73

what are the 2 types of HRS?

HRS1
-rapid progressive impairment in renal function (over 100% increase in creatinine in less than 2 weeks) í happens faster than HRS2

HRS2
-stable and less progressive impairment in renal function

74

what has the highest risk of developing HRS? means what?

development of infections (SBP) -> means need to dx and treat to improve survival

75

where should pts with HRS be monitored?

in the ICU

76

monitor what in HRS?

urine output, fluid balance, ideally CVP (in the ICU)

77

what do you screen for in HRS management?

sepsis screening
-blood and ascetic culture, ppx abx if no active infection

78

what meds to use for HRS management?

Vasopressin analogues
-improves renal fxn in Type 1 HRS

79

what replacement therapy should be done for HRS management?

renal replacement therapy (hemodialysis)
-hyperkalemia, volume, metabolic acidosis

80

___ transplant should be done ASAP for HRS

Liver transplant

81

what meds should be stopped if pt has HRS?

Diuretics

82

what is hepatic encephalopathy characterized as?

personality changes, intellectual impairment, and a depressed level of consciousness

83

why does ammonia build up in liver failure?

b/c have less hepatocytes able to detoxify the ammonia

84

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

85

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

86

what level should you get for hepatic encephalopathy?

ammonia level - get once, don't need to follow it

87

#1 medication for treatment of hepatic encephalopathy?

Lactulose - has laxative effect to remove nitrogenous wastes and bacteria

88

Lactulose dose to start

20-60ml 3x/day, titrated to achieve 2-4 soft stools/day without diarrhea

89

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

90

how can Lactulose be administered?

NGT or enema in hospitalized pts unable to take themselves

91

what are the 2nd line agents to treat hepatic encephalopathy?

Abx - Neomycin, Flagyl, PO Vanco, Rifaximin

-used after failure of Lactulose

92

when are abx used to treat hepatic encephalopathy?

after failure of Lactulose

93

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

94

if pt has ascites and Portal HTN what are clues that tell you this?

Portal HTN
-splenomegaly and large collateral veins (caput medusa)

95

if pt has ascites and cardiac problems/lymph nodes problems, what are some clues?

Cardiac
-engorged jugular veins

Lymph Nodes
-TB or Lymphoma