Disorders of Extracellular Fluid Volume: Cirrhosis Of the Liver

Question 1

What are the most common clinical findings in patients with severe liver disease?

Answer 1

Na+ and water retention, extracellular fluid (ECF) volume expansion, edema, and ascites.

Question 2

What initiates the clinical manifestations in cirrhosis?

Answer 2

Hepatic cell death.

Question 3

What are the pathological characteristics of cirrhosis?

Answer 3

Fibrosis and nodular regeneration.

Question 4

Which liver function tests are typically abnormal in cirrhosis?

Answer 4

Aminotransferases, bilirubin, alkaline phosphatase.

Question 5

What causes Na+ and water retention in cirrhosis?

Answer 5

Activation of salt- and water-retaining mechanisms.

Question 6

What is the effect of decreased effective arterial blood volume (EABV) in cirrhosis?

Answer 6

Activates neurohumoral vasoconstrictors and release of ADH.

Question 7

What role does ADH play in cirrhosis?

Answer 7

Promotes water reabsorption.

Question 8

What mediators contribute to splanchnic vasodilation in cirrhosis?

Answer 8

Nitric oxide, endotoxin, and prostaglandins.

Question 9

What is the role of atrial natriuretic peptide (ANP) in cirrhosis?

Answer 9

Resistance to ANP contributes to Na+ retention.

Question 10

What are the common presentations of patients with cirrhosis?

Answer 10

Dyspnea, abdominal discomfort due to ascites, and lower leg edema.

Question 11

What are important components of the clinical evaluation for cirrhosis?

Answer 11

History of medications, dietary salt intake, and physical examination.

Question 12

What laboratory tests are pertinent for evaluating cirrhosis?

Answer 12

Complete blood count (CBC), electrolytes, BUN, creatinine, glucose, liver function tests.

Question 13

What electrolyte abnormalities are common in cirrhosis?

Answer 13

Hyponatremia and hyper- or hypokalemia.

Question 14

What is the recommended dietary Na+ restriction for managing edema in cirrhosis?

Answer 14

88 mEq (2 g Na+) diet.

Question 15

When should water restriction be considered in cirrhosis patients?

Answer 15

When serum Na+ falls <130 mEq/L.

Question 16

What is the maximum dose of spironolactone for treating edema in cirrhosis?

Answer 16

400 mg/day.

Question 17

What should be done if there is no response to spironolactone?

Answer 17

Start furosemide 20–40 mg/day.

Question 18

What is the ideal weight loss goal for patients without edema?

Answer 18

Approximately 0.5 kg/day.

Question 19

What are the three theories proposed for the formation of ascites in cirrhotic patients?

Answer 19

Underfill, overfill, and peripheral vasodilation theories.

Question 20

What does the underfill theory suggest about ascites formation?

Answer 20

It begins with an imbalance of Starling forces in the hepatic sinusoids.

Question 21

What is the premise of the overfill theory?

Answer 21

Na+ retention precedes the development of ascites.

Question 22

What is the peripheral vasodilation theory regarding ascites?

Answer 22

Portal hypertension activates vasodilatory mechanisms leading to underfilling of the vascular space.

Question 23

What is the grading system for ascites based on fluid accumulation?

Answer 23

Grade 1 (small), Grade 2 (moderate), Grade 3 (large).

Question 24

What is the suggested treatment for Grade 1 ascites?

Answer 24

No treatment.

Question 25

What treatment is recommended for Grade 2 ascites?

Answer 25

Salt restriction and diuretics.

Question 26

What is the treatment of choice for Grade 3 ascites?

Answer 26

Large-volume paracentesis, followed by salt restriction and diuretics.

Question 27

What is the recommended starting dose of spironolactone for moderate ascites?

Answer 27

100 mg/day.

Question 28

What is the maximum dose of furosemide when used in combination with spironolactone?

Answer 28

160 mg/day.

Question 29

What should be monitored during diuretic therapy for ascites?

Answer 29

Serum K+ levels.

Question 30

What is the purpose of large-volume paracentesis (LVP) in ascites management?

Answer 30

To remove 5–7 L of fluid to relieve symptoms.

Question 31

What is the risk associated with large-volume paracentesis?

Answer 31

Post-paracentesis circulatory dysfunction (PPCD).

Question 32

What is the treatment of choice for patients with grade 3 ascites?

Answer 32

Entesis (LVP), removal of 5–7 L at one time, followed by administration of 6–8 g/L of albumin

Question 33

What condition is referred to as post-paracentesis circulatory dysfunction (PPCD)?

Answer 33

A reduction in effective arterial blood volume (EABV) after large volume paracentesis (LVP) leading to kidney failure, hyponatremia, hepatic encephalopathy, and decreased survival

Question 34

What is the role of plasma volume expansion in relation to PPCD?

Answer 34

It prevents post-paracentesis circulatory dysfunction (PPCD)

Question 35

What should patients receive after LVP to prevent reaccumulation of ascites?

Answer 35

A maximum dose of diuretics

Question 36

Which drugs are contraindicated in patients with ascites?

Answer 36

NSAIDs and aminoglycosides

Question 37

What is the effect of angiotensin converting enzyme (ACE)-inhibitors or angiotensin receptor blockers (ARBs) in patients with ascites?

Answer 37

They lower blood pressure and increase serum creatinine

Question 38

Is a contrast study contraindicated in a patient with normal kidney function?

Answer 38

No, it is not contraindicated

Question 39

What should be evaluated for a contrast study in a patient with kidney impairment?

Answer 39

The benefit–risk ratio

Question 40

How is refractory ascites defined?

Answer 40

Ascites that does not respond to salt restriction (<90 mEq/day) and maximum doses of diuretics

Question 41

What is the maximum dose of spironolactone for diuretic therapy?

Answer 41

400 mg

Question 42

What is the maximum dose of furosemide for diuretic therapy?

Answer 42

Not specified in the provided text