End stage liver disease

Question 1

Cirrhosis

Answer 1

slow, silent damage to the liver
-irreversible when advanced
-final stage of liver disease

Question 2

Compensated cirrhosis

Answer 2

normal liver function despite development of portal hypertension and progressive damage
-80% of patients can remain compensated for 10 years

Question 3

What are the functions of the liver?

Answer 3

main function is to filter the blood and detoxing harmful substances

Question 4

Which symptom of ESLD may limit a patient’s decision-making capacity?

Answer 4

encephalopathy

Question 5

Describe cirrhosis

Answer 5

fibrosis (scar tissue) and regenerative nodules, leading to permanent distortion in the liver architecture

Question 6

What blood tests are done for liver disease?

Answer 6

albumin, INR and bilirubin

Question 7

What are the symptoms and life-threatening conditions of decompensated cirrhosis?

Answer 7

-variceal hemorrhage and hepatoma
-ascites
-extreme fatigue
-pruritis
-cachexia
-cognitive decline (mild to severe with coma)
-psychological distress and depression

Question 8

What are the signs of liver complications and decompensation? (IMPORTANT FOR TEST)

Answer 8

-portal hypertension and esophageal varices
-peripheral edema and ascites
-spontaneous bacterial peritonitis
-hepatic encephalopathy
-hepatorenal syndrome

Question 9

Spider angiomas

Answer 9

small, red spots on the skin that resemble a spider’s body and legs– caused by dilated blood vessels

Question 10

Asterixis: liver flap

Answer 10

Asterixis, also known as “flapping tremor,” is a neurological sign characterized by a sudden, involuntary loss of muscle tone in the hands and wrists, often appearing as a flapping or shaking movement.

Question 11

What are the challenges surrounding decisions and palliative care?

Answer 11

1) difficulty predicting survival (lack of clear terminal phase)
2) even near EOL pts with chronic liver disease often benefit from disease-specific treatment
3) high risk of cognitive dysfunction that may impair decision-making capacity
4) hopes for life-saving transplanted available donors

Question 12

What is the max daily dose of Acetaminophen for pts with ESLD?

Answer 12

</= 2g/day

Question 13

Which classification of pain management should be avoided for pts with ESLD?

Answer 13

NSAIDS
-suppresses afferent vasodilatory effect of renal prostaglandins which decreases renal perfusion and GFR causing acute renal insufficiency
-anti-PLT effect could cause GI hemorrhage
-increases sodium and fluid retention
-cause GI ulceration

Question 14

Which opioid is best tolerated for mod-severe pain for pts with ESLD?

Answer 14

fentanyl– decrease dose 25-50%, and transdermal patch uses 50% of usual dose
-can also use methadone

Question 15

Which opioids should be AVOIDED by pts with ESLD?

Answer 15

-codeine
-morphine
-use hydromorphone with caution

Question 16

What are the medications for pruritis associated with ESLD?

Answer 16

1st line: cholestyramine (bile-acid sequestrant = ↓bile salts;
use 3-4x daily on empty stomach),

2nd line: rifampicin,

3rd line: naltrexone (do not
use on pts who are on opioids for pain – typically used to manage opioid/alcohol
dependence)

4th line: SSRI, Sertraline (not used often)

Question 17

What are the interventions for ascites management?

Answer 17

Non-pharm: alcohol cessation, sodium restriction, large-volume paracentesis (5-10L; must be infused w/ albumin for every 5L removed to prevent paracentesis induced circulatory dysfunction)

Pharm: spironolactone (RAAS antagonist), furosemide (works well if pt has adequate renal function)

Question 18

What is refractory ascites?

Answer 18

reserved for EOL, treatment includes serial LVP, indwelling peritoneal catheter, transjugular intrahepatic portosystemic shunt (TIPS)
-TIPS increases the risk for hepatic encephalopathy

Question 19

Spontaneous Bacterial Peritonitis

Answer 19

infection of peritoneal cavity d/t translocation of gut organisms

Question 20

What are the risk factors for Spontaneous Bacterial Peritonitis?

Answer 20

-ascites
-esophageal variceal bleeding

Question 21

What is done prophylactically for those at risk of spontaneous bacterial peritonitis?

Answer 21

prophylactic antibiotics to PREVENT SBP for 3 months

Question 22

What is the treatment for Spontaneous bacterial peritonitis?

Answer 22

Cefotaxime 2g IV q8h or Ceftriaxone 2g IV q24h
-aggressive fluid resuscitation
-IV albumin

Question 23

What is the treatment for hepatic encephalopathy?

Answer 23

lactulose orally– reduces pH of stool to acidify intestinal ammonia which increases excretion
(not be used as a laxative in this case, but will titrate up to 4 BMs/day)

Question 24

Hepatic encephalopathy

Answer 24

Altered level of consciousness associated with liver disease

partially reversible; d/t increased accumulation of ammonia and is a marker of a poor prognosis

Question 25

What are the signs and symptoms of hepatic encepholopathy?

Answer 25

anxiety/inattention, inappropriate behaviours, somnolence, euphoria, asterixis (flapping tremor)

Question 26

What are the possible triggers for hepatic encephalopathy?

Answer 26

 Infection: SBP  GI Bleed  Medications: opioids, benzodiazepines.  Any intercurrent illness.  Constipation  After life-saving TIPS procedure

Question 27

What is the management for hepatic encephalopathy?

Answer 27

Pharm: 1st line: lactulose (acidifies ammonia in gut to ↑ excretion, titrate to 4 loose BM/day); 2nd line: Rifaxamin (added to lactulose to alter gut flora) Non-pharm: maintain sensorium, reorient, calm and quiet environment, prevent over-stimulation

Question 28

Describe esophageal varices/bleeding

Answer 28

severely dilated veins in lower esphagus d/t portal HTN

Question 29

What are the methods for preventing esophageal varices/bleeding?

Answer 29

serial banding, betablockers,

Question 30

What are the pharm interventions for esophageal varices/bleeding?

Answer 30

octreotide ↓pressure in portal venous system, sedate with opioid/benzos

Question 31

What are the non-pharm interventions for esophageal varices/bleeding?

Answer 31

bleed kit (dark linens), position side-lying

Question 32

Describe hepatorenal syndrome

Answer 32

-progressive renal dysfunction due to advanced liver disease -prognosis: 85-95% mortality (weeks to ~3 months to live) -renal insufficiency: decrease urinary Na, decrease diuretic response, increase plasma Cr

Question 33

What is the treatment for hepatorenal syndrome?

Answer 33

stop diuretics, beta-blockers -Norepinephrine – requires central line & ICU - IV albumin 20% (concentrated) Q8H - Midodrine -Octreotide -Liver Transplant (if don’t return to normal kidney function within 6 wks post transplant can be placed on Kidney Transplant list)