OnlineMedEd: Intern Content - "Cirrhosis II"

Question 1

There is no such thing as acute exacerbations of cirrhosis. There are only compensated and uncompensated cirrhoses. What makes cirrhosis uncompensated?

Answer 1

• Ascites
• Hepatic encephalopathy
• Bleeding varices

Question 2

Review the three ways that ascites develops.

Answer 2

• Decreased albumin (lowered vascular oncotic pressure)
• Increased portal vein pressure (increased vascular hydrostatic pressure)
• Volume overload via RAAS

Question 3

True or false: SVR is up in those with cirrhosis.

Answer 3

False

Although the RAAS axis is stimulated in those with cirrhosis, the dilations in the splanchnic vasculature override the aldosterone-induced increase in SVR.

Question 4

Describe how ascites can be treated.

Answer 4

•Problem: Decreased albumin (lowered vascular oncotic pressure)
- Treatment: Do not use colloid –it wears off quickly

•Problem: Increased portal vein pressure (increased vascular hydrostatic pressure)
- Treatment: TIPS

•Problem: Volume overload via RAAS

• Treatment 1: Give furosemide and spironolactone
• Treatment 2: Restrict NaCl to < 2 g/day and fluid to < 2 L/day
• Transplant can be curative.

** Therapeutic paracentesis can provide symptomatic relief.

Question 5

LIst the diagnostic criteria for spontaneous bacterial peritonitis.

Answer 5

Paracentesis showing any of the following:
•> 250 PMNs/mL
•Culture positive

If the culture shows 2 or more bacteria, then there is likely a perforation somewhere. Do an ex-lap.

Question 6

A SAAG greater than 1.1 means _____________.

Answer 6

that the ascites is 2/2 portal HTN

Question 7

A SAAG less than 1.1 means _______________.

Answer 7

that the ascites is inflammatory so SBP is a higher likelihood

Question 8

Review the management of bleeding esophageal varices.

Answer 8

• First, you don’t know it’s from the esophagus so treat it like any GI bleed: two large IVs, fluid transfusion, type and screen, page GI, do an EGD.
• Second, on the EGD you can do banding or sclerotherapy.
• If they are bleeding severely, you can stabilize with a Blakemore tube.
• • Octreotide can decrease the pressure of the portal system.

Question 9

After an acute esophageal bleed, treat with prophylactic ____________.

Answer 9

propranolol or nadolol

Question 10

Describe the stages of hepatic encephalopathy.

Answer 10

• I: mild nonspecific confusion (“I always forget my keys.”); no asterixis
• II: moderate AMS (e.g., not knowing where they are but otherwise stable); positive asterixis
• III: belligerent (thrashing around, incomprehensible); + asterixis
• IV: comatose

Question 11

The three treatments for hepatic encephalopathy are _________________.

Answer 11

lactulose, rifaximin, and zinc (for bowel movements)

Question 12

When someone with cirrhosis presents with sudden worsening, it is likely one of three things: __________________.

Answer 12

fluid status, infection, bleed