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complications of liver disease Flashcards

(58 cards)

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1
Q

what are 3 complications of liver disease

A

ascites (SBP) , varices, encephalopathy

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2
Q

primary prevention for variceal hemorrhage

A

non-selective beta blockers: nadolol, propranolol, carvedilol

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3
Q

how to titrate beta blocker dose

A

every 2-3 days to maximum tolerated dose, HR 55-60 bpm and BP >90/60 mmHg

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4
Q

whats the beta blocker duration

A

indefinite

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5
Q

general treatments for acute variceal bleed

A

IV fluids, blood transfusions, vasoconstriction + endoscopic therapy, short term antibiotics

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6
Q

which IV fluids are preferred for acute variceal bleed

A

NS, LR

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7
Q

blood transfusions maintain hemoglobin > ___

A

8 gm/dL

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8
Q

how many days should you do a vasoconstriction agent

A

5

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9
Q

what are the vasoconstriction agents

A

octreotide and vasopressin

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10
Q

which vasoconstriction agent is preferred

A

octreotide

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11
Q

how many days should you do antibiotics for acute variceal bleed

A

7

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12
Q

what antibiotics are preferred for acute variceal bleed

A

3rd generation cephalosporins, alternative is fluoroquinolones. start IV then switch to PO

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13
Q

octreotide dose?

A

IV bolus 25-100 mcg, continuous 25-50 mcg/hr

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14
Q

octreotide adverse

A

bradycardia, hypertension, nausea, abdominal cramps, diarrhea, malabsorption of fat, hyperglycemia

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15
Q

vasopressin dose?

A

0.2-0.4 units/min IV infusion (max 0.8 units/min)

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16
Q

vasopressin adverse

A

hypertension, severe headache, coronary and mesenteric ischemia, bowel ischemia, non-selective vasoconstriction

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17
Q

therapy for secondary prevention of variceal hemorrhage

A

non-selective BB titrated to achieve a goal HR of 55-60 bpm or the maximal tolerated dose PLUS endoscopic variceal ligation q1-2weeks until obliteration, followup 3-6mo then q6-12mo

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18
Q

how to calculate SAAG (serum ascites albumin gradient)

A

serum albumin-ascitic albumin

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19
Q

if SAAG is > ___, the patient almost certainly has portal hypertension

A

1.1 g/dL

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20
Q

general treatment approaches to ascites

A

sodium restriction, diuretics, therapeutic paracentesis, abstinence from alcohol

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21
Q

how should sodium be restricted with ascites

A

<2 grams per day

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22
Q

how should you give diuretics for ascites

A

spironolactone PLUS furosemide (100:40)

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23
Q

what fluids should you give for therapeutic paracentesis for ascites

A

if >5 L removed, give 6-8 gm 25% albumin as IV infusion per 1 L ascites removed

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24
Q

when should you do fluid restriction with ascites

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A

only in severe hyponatremia (Na <125)

25
if the patient cannot tolerate spironolactone + furosemide, which one is preferred
spironolactone
26
spironolactone dosing
initial dose 100 mg, max dose 400 mg/day
27
spironolactone concerns?
hyperkalemia, gynecomastia, lower extremity cramps, increase in SCr and BUN
28
furosemide dosing
initial dose 40 mg/day, max dose 160 mg/day
29
furosemide concerns
electrolyte imbalance, SCr, BUN, lower extremity cramps
30
initial goal of diuretic therapy
daily weight loss of 0.5 kg until patient is euvolemic
31
how often to up-titrate diuretic dose
every 3-5 days
32
how long to give diuretics
typically lifelong
33
when to discontinue or hold diuretic therapy
uncontrolled encephalopathy, severe hyponatremia (Na <120) despite fluid restriction, renal insufficiency (SCr >2)
34
drugs to avoid in patients with ascites
ACEi, ARB, NSAID
35
options for diuretic refractory patients
midodrine 7.5 mg TID (to inc BP to allow up titration of diuretic), serial therapeutic paracentesis, liver transplant, transjugular intrahepatic portosystemic stent-shunt
36
symptoms of SBP?
ascites may be the only symptom. others: fever, abdominal pain, unexplained encephalopathy
37
most common organisms of SBP
E. coli, klebsiella, strep pneumoniae
38
how to diagnose SBP
diagnostic paracentesis to assess WBC count. PMN> 250 cells/mm3 is infection
39
how to calculate PMN
[WBC x (% neutrophils + % bands)]
40
should you wait for SBP culture before initiating antibiotics
NOPE
41
1st line for SBP treatment
cefotaxime 2 gm IV q8h x 5d, ceftriaxone 2 gm IV q24 h x 5 days
42
second line for SBP treatment
cipro 400 mg IV or 500 mg PO q12h x 8 days, ofloxacin 400 mg PO q12h x 8 days
43
when do you give SBP patient albumin
if SCr>1, BUN>30, or bilirubin >4
44
how do you give albumin for SBP
albumin 25% IV infusion 1.5 g/kg on day 1 and 1 g/kg on day 3
45
why do you give albumin for SBP
improved survival
46
when do you give SBP indefinite prophylaxis
SBP infection, or ascitic protein <1.5 and one of the following: SCr >1.2, BUN>25, Na <130, child pugh C with bilirubin >3
47
what do you give for indefinite prophylaxis
SMX-TMP or cipro daily
48
what is the dose for SBP prophylaxis during GI bleeding
ceftriaxone 1 gm IV q24h x 7d, cefotaxime 1 gm IV q8h x 7d. can switch to oral bactrim DS BID or cipro 500 BID once the patient is stable and eating
49
alternatives for SBP prophylaxis during GI bleeding
cipro 400 mg IV q12h, cipro 500 mg po q12h
50
mechanism of lactulose for HE
causes a laxative effect that reduces the time period available for ammonia absorption, metabolized by gut flora into acetic acid and lactic acid which lowers colonic pH and traps NH3 in colon as NH4+
51
dose for episodic HE
30 mL PO q1-2h until evacuation
52
dose for chronic HE
15-45 mL PO q8-12h, titrated to 2-3 SOFT stools daily
53
lactulose side effects
severe diarrhea, electrolyte disturbances, hypovolemia
54
lactulose counseling points
abdominal distention, bloating, take with or without food, full glass of water, juice or milk improve taste, can be used in feeding tubes (dilute with water and flush tube before)
55
PEG 3350 dose
255 gm in 4 L ONCE: not for use in chronic
56
PEG side effects
cramping, electrolyte disturbances
57
antibiotics for HE MOA
reduce NH3 forming bacteria in colon
58
rifaximin dose
550 mg PO BID or 400 mg PO TID

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