Cirrhosis & Hepatic Failure Flashcards by Andrew Kreutzer

Compensated Cirrhosis
s/sx

usually asymptomatic

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Uncompensated Cirrhosis
s/sx

ascites (most freq sign)
variceal bleeding
encephalopathy

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Some Causes of Cirrhosis include?

ETOH
Chronic Viral Hepatitis (B/C)
NASH
Primary biliary cirrhosis
Primary sclerosing cholangitis
Autoimmune hepatitis
Hereditary hemochromatosis
Wilson Dz
Alpha-1-antitrypsin deficiency

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Cirrhosis Physical findings include

variable
palmer erythema
gynecomastia
splenomegaly
ascites
caput medusa
jaundice
Spider aniomata
dupuytren’s contracture
asterixis
muscle wasting
edema
encephalopathy

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Cirrhosis abdominal exam includes

+/- pain
distention & visible dilation of collateral veins c/w advanced dz
ascites
Fluid wave on percussion
shifting of tympanic to dull sound

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Cirrhosis Liver exam
Normally spans how far in MC line?
May be diminished in? or large in?
borders should be what? felt up to how fare below R costal margin?
Feels how in cirrhosis? feels how in acute viral hepatitis?

6-12cm
cirrhosis; CHF, NASH, viral hepatitis
smooth; 2cm
hard, irregular; tender enlarged smooth

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Spleen
Splenomegaly: dullness b/t where?
Palpable spleen tip suggests what?

9-11th ribs L midaxillary line
portal HTN

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Other S/Sx of Cirrhosis?

fatigue, anorexia
pruritus (cholestatic d/os like: PBC, PSC, acute/chronic hepatitis)
Rales, JVD suggests CHF, pericardial dz
peripheral edema in decompensated cirrhosis

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Cirrhosis Lab Work up
LFT?
Alk phos?
GGT
Bilirubin?
Albumin?
PT/INR?
Sodium?
Platelets?

mild-mod elevation
elevated
elevated
may be subtle; rises with progression
may be subtle; decreases
increased
hyponatremia
thrombocytopenia (< 150,000; most sensitive/specific in chronic dz)

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ETOH Hepatitis
Disproportionate elevation of AST compared to ALT (what ratio) with both values being?

2:1
< 300

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Primary Biliary Cirrhosis Hallmark sign is?

anti-mitochondrial antibodies (AMA) in serum

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Primary Sclerosis Cholangitis
H/o?
Cholangiogram show?

UC/IBD
diffuse strictures

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Autoimmune Hepatitis
Hyperglobulinemia with specific autoantibodies which include?
What can assist in diagnosis?

ANA, Anti-smooth muscle, antiactin
Liver bx

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Hereditary hemochromatosis
Fasting transferrin saturation >/= what in men? & >/= what in women?
Plasma ferritin concentration is > what in men & > what in women?
Requires what type of testing?
What can diagnose?

60% in men; 50% in women
300ng/mL in men & 200 ng/mL in women
genetic
liver bx

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Alpha-1 Antitrypsin deficiency
Clinical/biopsy suspicion
Check what? confirm with what?

serum AAT concentrations
phenotyping

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Viral Hepatitis
ALT/AST
Bilirubin
Alk phos
Albumin
INR

Increased
/
/
decreased
increased

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ETOH hepatitis
ALT/AST
Bilirubin
Alk phos
Albumin
INR

Increased
/
/
/
Increased

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Biliary obstruction
ALT/AST
Bilirubin
Alk phos
Albumin
INR

/
Increased
increased
/
/

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Cirrhosis
ALT/AST
Bilirubin
Alk phos
Albumin
INR

Increased
/
/
decreased
increased

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Wilson Dz
ALT/AST
Bilirubin
Alk phos
Albumin
INR

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/
Increased
decreased
/
/

Acetaminophen Tox
ALT/AST
Bilirubin
Alk phos
Albumin
INR

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Increased
decreased
/
/
/

Diagnostics & imaging include?

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Biopsy (gold standard)
U/S
CT
MRI (small liver with nodular contour, splenomegaly, collateral vessels)
Trans-jugular pressure measurements
Endoscopy (screen for varices in cirrhosis to determine need for hemorrhage prophylaxis)

Trans-jugular pressure measurements
to assess cause of what? and need for?
Hepatic venous pressure gradient is the gradient between?
NL is what? and is present if cause of portal HTN is what?
>/= what predicts complications of portal HTN?

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portal HTN, med titration
wedged hepatic venous pressure: free hepatic/IVC pressure)
3-5; if pre-hepatic or pre-sinusoidal
10

Biomarkers and complications associated with increased risk of decompensation and death
Low risk
Platelet count?
Liver stiffness?
Hepatic venous pressure gradient?

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> /= 150 x 10^9/L
<10kPa
<5mmHg

Biomarkers and complications associated with increased risk of decompensation and death Indeterminant risk Platelet count? Liver stiffness? Hepatic venous pressure gradient?

110-149 x 10^9/L 10-19 kPa 5-9 mmHg

Biomarkers and complications associated with increased risk of decompensation and death High risk Platelet count? Liver stiffness? Hepatic venous pressure gradient?

< 110 x 10^9/L >/= 20 kPa >/= 10 mmHg

Variceal Bleeding management includes?

Variceal band ligation IV octreotide Antibiotics nonselective Beta-blockers

Ascites Management includes?

Aldosterone antagonists diuretics TIPS

Spontaneous Bacterial peritonitis management includes?

antibiotics albumin

Hepatorenal syndrome management medications include?

Terlipressin norepinephrine

Hepatic Encephalopathy Management includes?

Lactulose Rifaximin High-protein diet

Compensated Cirrhosis Synthetic function? Portal pressure is where? commonly patients are? they may or may not have?

mostly NL below threshold required for varices/ascites fatigue varices

Cirrhosis management is directed @ what? tx includes? Caloric intake required? protein?

prevention of decompensation underlying dz (antivirals, avoid ETOH, meds, screening for varices & HCCA) 25-35 kcal/kg/d; 1-2g/k/d

Decompensated Cirrhosis Portal HTN increased resistance to portal flow from what? leads to what? and what?

fibrosis, vasoconstriction --> splenomegaly liver insufficiency

Ascites Management First line treatment in patients with cirrhosis and grade 2 ascites includes? Is fluid restriction necessary? What should be monitored regularly when patients are receiving diuretics? What is the first line treatment for Grade 3 ascites? after treatment what should be started? Referral for what should be considered in patients with grade 2 or 3 ascites? Drugs to avoid in patients with ascites include?

moderate sodium restriction (2g or 90 mmol/day) and diuretics (spironolactone w/ or w/o furosemide) only if there is concomitant moderate or severe hyponatremia body weight and serum creatinine and sodium Large Volume Paracentesis; sodium restriction and diuretics Liver transplant NSAIDs

Primary Prophylaxis for "high risk varices": small varices with red signs or Child-Pugh C is what? Med or Lg varices is what? Bleeding varices?

Non-selective beta blockers (propranolol, nadolol, carvedilol) NSBB or endoscopic band ligatio NSBB + EBL for secondary prophylaxis

Management of Pts with Mod/Large Varices That Have not Bled Propranolol Recommended dose? Adjust how frequently? Maximal daily dose? Therapy Goals are: HR? SBP? Follow up: check what at every outpatient visit? Continue how long? when to do EGD?

20-40 mg PO BID q2-3 days until treatment goal is achieved 320mg/day in patients w/o ascites; 160mg/day in patients with ascites Resting HR of 55-60 bpm; SBP shouldnt decrease < 90 mmHg make sure HR is on target, continue indefinitely, no need for follow up EGD

Management of Pts with Mod/Large Varices That Have not Bled Nadolol Recommended dose? Adjust how frequently? Maximal daily dose? Therapy Goals are: HR? SBP? Follow up: check what at every outpatient visit? Continue how long? when to do EGD?

20-40mg PO daily q2-3 days until treatment goal achieved 160mg/day in patients w/o ascites; 80mg/day in patients with ascites Resting HR of 55-60 bpm; SBP should not decrease < 90 mmHg Make sure HR is on target, continue indefinitely, no need for follow up EGD

Management of Pts with Mod/Large Varices That Have not Bled Carvedilol Recommended dose? Adjust how frequently? Maximal daily dose? Therapy Goals are: HR? SBP? Follow up: check what at every outpatient visit? Continue how long? when to do EGD?

Start w/ 6.25mg PO daily after 3 days increase to 6.5 mg PO BID 12.5mg/day (except in patients with persistent arterial HTN) SBP should not decrease < 90 mmHg Continue indefinitely, no need for follow up EGD

Acute GI bleeding + portal HTN Initial assessment includes? Immediate start of drug therapy includes? Antibiotic prophylaxis includes?

Hx, PE, Blood exam, cultures, resuscitation somatostatin/terlipressin ceftriaxone or norlaxacine

Vasoactive agents used in the management of acute variceal hemorrhage Octreotide Initial bolus? Continuous infusion? Duration?

50mcg (can be repeated in first hour if ongoing bleeding) 50mcg/hr 2-5 days

Vasoactive agents used in the management of acute variceal hemorrhage Vasopressin Continuous infusion? Should be accompanied by? Duration?

0.2-0.4 U/min; can be increased to 0.8 U/min IV nitro at a starting dose of 40mcg/min, wich can be increased to a max of 400mcg/min to maintain sbp of 90 mmHg 24 hrs

Vasoactive agents used in the management of acute variceal hemorrhage SMT Initial bolus? Continuous infusion? Duration?

250mcg (can be repeated in the first hr if ongoing bleeding) 25-500mcg/hr 2-5 days

Vasoactive agents used in the management of acute variceal hemorrhage Terlipressin (VP analogue) Initial 48hrs? Maintenance? Duration?

2mg IV q 4 hr until control of bleeding 1mg IV q 4 hr to prevent rebleeding

Encephalopathy NH3 accumulation d/t what/ Hallmark sign is? look for what? ID what? & correct Empirical tx includes? Daily energy intake should be? Daily protein intake should be?

reduced liver metabolism asterixis other causes of AMS precipitating factors lacutlose & rifaximin 35-40 kcal/kg IBW 1.2-1.5g/kg/day

Encephalopathy empirical tx Lactulose increases stool what? Dose? Goal?

H2O content, acidity, traps NH4 ions 30-45ml TID-qid 2-3 soft stools/d

Encephalopathy empirical tx Rifaximin Diminishes enteric bacteria which leads to? Dose?

decreased production of nitrogenous compounds 550mg BID

Liver Dz Scoring Systems

Child-Pugh MELD

Cirrhosis & Hepatic Failure Flashcards

(48 cards)