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85 Cards in this Set
- Front
- Back
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What is portal hypertension?
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Portal venous pressure gradient greater than 5mmHg
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What causes portal hypertension?
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Two hemodynamic proccesses happening simultaneously: increased intrahepatic resistance to the passage of blood flow through the liver due to cirrhosis and regenerative nodules AND increased splanchic blood flow secondary to vasodilatation within the splanchic vascular bed
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What is WHVP measurement?
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Wedged hepatic venous pressure measurement - obtained by placing a catheter in the hepatic vein and wedging it into a smaller branch or by inflating a ballon and occluding a larger branch of the hepatic vein
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What are complications of portal hypertension?
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gastroesophageal varices, ascites, hypersplenism
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What is ascites?
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The accumulation of fluid in the peritoneal cavity
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What is the most common major complication of cirrhosis?
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ascites
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What causes ascites?
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Usually secondary to cirrhosis, but can be caused by CHF, pancreatitis, malignancy
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What is the role of diagnostic paracentesis in noncirrhotic and cirrhotic pts?
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for noncirrhotic pts diagnostic paracentesis is essential, for well established cirrhotic pts, the role is unclear
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What does the diagnostic paracentesis consist of?
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Aspiration of 10-20ml of ascites fluid to review for polymorphonuclear (PMN) count, albumin, total protein, and culture
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What is SAAG??
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Serum-to-ascites albumin gradient
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How is SAAG calculated and what results constitute portal hypertension?
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SAAG= Albumin serum - albumin ascites; gradient > 1.1 = portal hypertension
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What is the complication rate of paracentesis?
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LOW
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Are low platelets and increased PT contraindications in paracentesis?
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no
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If the fluid from paracentesis is translucent or yellow, what is the association?
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normal/steril
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If the fluid from paracentesis is brown, what is the association?
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hyperbilirubinemia (most common), gallbladder or bilary perforation
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If the fluid from paracentesis is cloudy or turbid, what is the association?
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infection
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If the fluid from paracentesis is pink or blood tinged, what is the association?
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mild trauma at site
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If the fluid from paracentesis is grossly bloody, what is the association?
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malignancy or abominal trauma
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If the fluid from paracentesis is milky, what is the association?
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Cirrhosis, thoracic duct injury, lymphoma
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What are the mainstays in the treatment of ascites?
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minimization of intraperitoneal fluid without intravascular volume depletion, minimizing alcohol consumption, nsaids, and dietary sodium; routine paracentesis, transjugular intrahepatic portosystemic shunt (TIPS), liver transplant
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What are the low volume ascites treatments?
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usually not pharmacologic, cessation of ETOH can lead to decreased fluid and improved response to medical therapies even if alcohol is not the cause of the liver disease, no nsaid, sodium intake of 2 gm/d
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What are the drugs used in moderate volume ascites?
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Spironolactone (aldactone) and furosemide (lasix)
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What is the starting dose of Spironolactone and furosemide in moderate volume ascites?
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Spironolactone 100mg and Furosemide 40 mg po
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What is the ratio of spironolactone to furosemide in moderate volume ascites? Why?
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5:2 ratio of spironolactone to furosemide to maintain normal electrolyte balance
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What is the max dose of spironolactone and furosemide in moderate volume ascites?
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spironolactone 400mg and furosemide 160mg / d
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What is the max acceptable weight loss for a patient without edema per d?
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0.5kg/d
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What is the max accceptable weight loss for a patient with edema per d?
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1kg/d
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What is the trade name for spironolactone?
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aldactone
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What is the class for spironolactone?
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Potassium sparing diuretic, selective aldosterone blocker
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What is the alternative to spironolactone if side effects are intolerable?
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amiloride
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For all indications (not just ascites) what is the starting dose for spironolactone? max dose?
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25-50mg po starting, 400mg/d max
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What are the SE of spironolactone?
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N/V/D, gyneocomastia, hyperkalemia, increase BUN, renal failure, urticaria (hives), ataxia, confusion
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What is the trade name for furosemide?
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lasix
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What is the class for furosemide?
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loop diuretic
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What is the starting dose (not just for ascites) for furosemide? Max dose?
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starting dose is 20mg po up too max 600mg/d
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What are the SE of furosemide?
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NVD, hypotension, pruritis, urticaria, gout, muscle weakness, parethesias, electrolyte disturbances
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What characterizes large volume ascites?
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Intraperitoneal fluid that significant limits the activities of daily life due to the large volume
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Why use colloids after paracentesis?
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can prevent changes in serum electrolytes, creatinine, renin levels; to prevent derangement of circulatory function (reduction of effective arterial blood volume and activation of vasoconstrictor and antinatriuretic factors
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What dose of albumin is usually give after ascites removal? What is the min amount of fluid removed before albumin is used?
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5-10 g/L of ascites removed. Min 5 L of ascites removed before albumin use
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What strengths of albumin are available?
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5% and 25% strengths
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What category of drugs is albumin?
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colloid plasma volume expander, blood product derivative
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What is the usual dose of albumin in all indications?
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0.5 - 1gm/kg
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What pts are indicated for 5% albumin use?
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hypovolemic pts or intravascularly depleted pts
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What pts are indicated for 25% albumin use?
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pts with fluid and soium intake is restricted
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How long after opening albumin must it be used?
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within 4 hours
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What is the rate of infusion for 5% albumin?
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do not exceed 2-4ml/min in pts with normal plasma vol; 5-10ml/min in pts with hypoproteinemia
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What is the rate of infusion for 25% albumin?
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do not exceed 1 ml/min in pts with normal plasma volume; 2-3ml/min in pts with hypoproteinemia
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What is refractory ascites?
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type of ascites that occurs in 5-10% of pts. Characterized by lack of response to high dose diuretics while being compliant with low sodium diet, frequent ascites recurrence shorty after therapeutic paracentesis, recurrent side effects from diuretic therapy, renal insufficiency, or hepatic encephalopathy
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What is the treatment for refractory ascites?
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large volume paracentesis, TIPs, liver transplant
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What is TIPS?
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Transjugular intrahepatic porto-systemic shunt; artificial channel in the liver from the portal vein to a hepatic vein; decreases vascular resistance in the liver to decrease portal pressures to lessen ascites formation and visceral bleeding
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What is the survival rate benefit of TIPS over large volume paracentesis?
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none
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What is the problem with TIPS?
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High rate of stenosis (up to 75% after 6-12 months)
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What are the signs and symptoms of SBP?
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fever, ab pain, unexplained encephalopathy
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How is SBP diag'd?
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positive ascitic fluid bacterial culture and elevated PMN count (>=250 cells/mm^3) w/o evident intraabdominal or surgically treatable source of infection
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What is performed to confirm SBP?
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paracentesis
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What is the pathogenesis of SBP?
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intestinal bacterial overgrowth, increased intestinal permeability, translocation of bacteria from intestines to lymph nodes which transports bacteria to ascitic fluid and blood infection
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What are the common pathogens in SBP?
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E. Coli, Klebsiella pneumoniae, streptococcus pneumoniae
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What is the treatment for SBP?
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3rd gen cephalosporin like Cefotaxime 2g IVBP q8h x 5 days
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What is the treatment for SBP in a pt with PCN allergy?
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Cipro 400mg IVPB q12h
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What is the MOA of cefotaxime?
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inhibits bacterial cell wall synthesis by bindingto and inhibiting pcn binding proteins which lead to a defective cell wall and cell lysis
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What is the usual dose of cefotaxime?
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2g q8h iv
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When must cefotaxime be renally adj?
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when CrCl < 50 ml/min
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What is the dosing for Levaquin in SBP?
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500-750 iv q24h
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What is the MOA of Cipro or levaquin?
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interference with bacterial DNA gyrase
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What are the adverse effects of fluoroquinolones?
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HA, dizziness, insomnia, phototoxicity, rash, proarrythmic, hypo and hyperglycemia, arthropathies
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What are the oral meds to be used in SBP?
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Ofloxacin 400mg BID or Cipro 750mg po bid (avoid divalent cations due to chelation)
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When should albumin be given in SBP tx?
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when scr > 1mg/dl AND BUN >30mg/dL OR total bilirubin > 4mg/dl
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What is the tx for prophylaxis of secondary bacterial peritonitis?
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Bactrim DS po qd, Cipro 750mg q wk, Cipro 500mg qd, Ofloxacin 400mg qd
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Who should receive long term SBP prophylaxis?
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Anyone who survives an episode of SBP, pts with cirrhosis and ascits (but no gastrointestinal bleeding) with ascitic fluid total protein < 1g/dl or total bilirubin > 2.5mg/dl
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Who should receive primarly prophylaxis for SBP?
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Ascitic fluid protein < 1.5g/dl and one of the following: scr >=1.2 mg/dl , BUN >= 25 mg/dl , serum sodium <= 130 mEQ/l , Child Pugh >= 9 with bilirubin >= 3mg/dl
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What is the presentation in hepatorenal syndrome?
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oliguria
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How is hepatorenal syndrom diag'd?
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Diag of exclusion. Must exclude volume depletion (rapid diuresis), HRS worsens after diuretics are stopped
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What is type 1 hepatorenal syndrome?
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rapidly progressive renal failure, doubling of scr to level greater than 2.5mg/dl or a halving of the CrCl to less than 20 ml/min over a period of less than two weeks, mortality rate exceeding 50% at one month
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What is type 2 hepatorenal syndrome?
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slower in onset and progression, increase in SCR to 1.5mg/dl or CrCl of less than 40 ml/min and a urine sodium < 10 umol/l, median survival of 6 months unless liver transplant
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What is the pathogenesis of hepatorenal syndrome?
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not clearly defined. Hepatic dz leads to splanchinic vasodilation with subsequent reduced renal perfusion leading to renal failure
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What are the treatments for HRS?
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midodrine and octreotide
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What is the trade name of midodrine?
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Proamatine
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What is the trade name of octreotide?
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sandostatin
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How does midodrive work?
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selective alpha 1 adrenergic agonist which acts as a systemic vasoconstrictor
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How does octreotide work?
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its a somatostatin analog which is an inhibitor of endogenous vasodilator release to prevent splenic vasodilation
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What is dose in HRS of midodrine?
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7.5- 12.5 mg po tid
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What are the adverse effects of midodrine?
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hypertension, paresthesias, urinary retention, urinary frequency, pruritis
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What is the dose in HRS of octreotide?
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100-200mcg subq tid
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What are the adverse effects of octreotide?
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injection site pain, hyperglycemia, cholelithiasis, pancreatitis, sinus bradycardia, sinus dysrhythmias
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What are alternative treatments for hepatorenal syndrome?
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Norepinephrine with albumin (requires ICU care), can reverse type 1 HRS
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