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57 Cards in this Set
- Front
- Back
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what are complications of CLD
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esophageal varicies
hepatic encephalopathy spontaneous bacterial perotinitis hepatorenal syndrome bleeding disorders ascites hepatocellular carcinoma |
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at what hepatic venous pressure gradient do esophageal varices form
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> 8-10 mmHg
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what is the pathophysiological cause of esophageal varicies
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increase resistance in portal vein causing back up of blood
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what kind of bleed is it when esophageal varicies rupture
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GI bleed
high mortality when ruptures occur |
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what is the done to prevent Variceal bleeding
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non selective Beta blockers (propranolol, nodolol)
endoscopic therapies (sclerosing, band ligation) TIPS combo therapy |
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how do propranolol, nodolol help prevent variceal bleeding
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decrease hepatic blood flow so you have less blood going to the liver (constriction of mesenteric vein)
B2 blockage decreases blood going into protal vein |
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what are the endoscopic therapies and what do they do
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sclerosis - inject something into blood vessels to die off so no longer at risk for rupturing
band ligation - wrap band around blood vessels so it shrivels up and dies so no longer at risk for rupturing |
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what are TIPS
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go in via jugular vein feed catheter down into liver and SET UP SHUNT FROM PORTAL VEIN TO IVC
so instead of blood going through the liver and out the hepatic vein, blood will flow out of the portal vein also and through the IVC giving another outlet for blood which will decrease the pressure in the portal vein |
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what are the issues with TIPS
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make encephalopathy worse b/c since you're shunting blood away from the liver it won't get a chance to detoxify blood so you have a build up of things liver should metabolize
they get clogged up/occluded and therefore don't last forever |
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when are routine endoscopies done
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when pt diagnosed with cirrhosis
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what are the treatment options for Variceal bleeding
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manage fluid loss (give enough Na to maintain intravascular volume) and correct bleeding disorder (vit K, platelets, plasma)
manage bleeding prevent rebleeding treat SBP unless ruled out |
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how do you manage variceal bleeding
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somatostatin or octreotide
endoscopic therapies (sclerosing, band ligation) combination therapy salvage therapy (TIPS, ballon tamponade, surgery) |
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how does somatostatin/octreotide work
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cause constriction of mesenteric vein resulting in a decrease in the amount of blood reaching the portal vein therefore decrease portal pressure
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aside from somatostatin/octreotide what can be used to treat variceal bleeding
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vasopressin + nitroglycerin
works at mesenteric vein as well, only issue is VASOPRESSIN INCREASES BP THEREFORE GIVEN W/ NITROGLYCERIN |
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in treating variceal bleeding why would you put a pt on drugs before conducting an endoscopy
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the drugs would decrease the amount of bleeding occuring allowing you to find the varicies with the endoscope
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what is balloon tamponade
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place balloon in pt esophagous which will put pressure on the varices decreasing the amount of blood coming out
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what is the main treatment for variceal bleeding
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octreotide + endoscopic therapy
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why is it crucial to treat SBP unless it is ruled out
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pt with SBP tend to go down hill
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what is the pathophysiology of ascites
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resistance to hepatic blood flow
decrease oncotic pressure (decrease albumin) increase Na retention |
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how can resistance to hepatic blood flow result in ascites
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serous fluid oozes out of the blood vessels into the abdomen
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what are some things that can cause increase Na retention
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decrease aldosterone metabolism
decrease renal blood flow systemic vasodilation |
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what is the volume status of pt with ascites
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volume overloaded but intravascularly volume depleted
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how do you treat ascites
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Na retention +/- fluid retention
spironolacton + furosemide paracentesis TIPS or surgical shunt |
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how does spironolactone help ascites and why is it given with furosemide
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spironolactone is an aldosterone Rc antagonist and one of the causes of ascites is increased Na retention due to decreased aldosterone metabolism
furosemide is given also due to spironolactone being a subpar diuretic |
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what is the reason we diures pt with ascites and why is it critical when treating ascites that we don't diures too fast
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diuresis is done b/c we remove fluids from BV so fluid from the abdomen can replace it, only issue is that EASY TO TAKE FLUID OUT OF VASCULATURE BUT IT TAKES TIME FOR FLUID TO MOVE FROM ABDOMEN TO BV
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what is paracentes
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use needle to drain fluid out of the abdomen
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how much fluid would you have to take off to require albumin administration with paracentesis and what is a major draw back of paracentesis
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albumin administration done when you take off >5L of fluid
-albumin given just to maintain IV volume but only temporary fix b/c albumin t1/2 in BV is 24hrs major drawback is that the fluid reaccumulates |
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what will increase your risk of SBP infection
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ascites
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what is spontaneous bacterial peritonitis
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infection of ascites fluid
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what are some of the causative organisms of SBP
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enterobacteriaceae
pneumococcus enterococcus anaerobes |
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what is the clinical presentation of SBP
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pt more confused
ascites gets worse variceal bleeding |
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when is prophylaxis given in SBP
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after first attack since it has a high reoccurance and mortality
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what is given for acute SBP therapy
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ceftriaxone, cefotaxime
beta latams, beta lactamase inhibitors ertapenem fluoroquinolone short term IV albumin to decrease risk of renal failure |
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what is given for prophylaxis in SBP therapy
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Trimethoprim/Sulfamethoxazole (Bactrim) 5 times a week
or large dose of ciprofloxacin weekly |
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what is seen in Hepatic encephalopathy
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alteration of mental status due to accummulation of metabolites or alteration in BBB
asterixis |
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what is asterixis
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flapping of the hands due to false NT being present due to lack of liver detox
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encephalopathy from liver disease leans towards?
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somnolence
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what is hepatic encephalopathy often associated with
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increased ammonia levels
but ammonia levels don't correlate with severity of encephalopathy |
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what are the precipitating factors of hepatic encephalopathy
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excess dietary protein
constipation azotemia SBP GI hemorrhage electrolyte disturbances shunts CNS depressants |
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what electrolyte disturbance predisposes pt to encephalopathy
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hypokalemia
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what precipitating factor is a major cause of encephalopathy and why
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constipation (due to increased nitrogen load)
causes altered mental status GI contents sitting in colon giving body more chance to absorb ammonia |
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why do shunts lead to encephalopathy
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move blood from portal vein to IVC thereby bypass livers ability to detox
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how do you treat hepatic encephalopathy
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dietary protein restriction (1g/kg/day)
lactulose (osmotic laxative) rifaximin flumazenil Zn |
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how does lactulose treat encephalopathy
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prevents and tx constipation
decrease bowel pH (therefore ammonia and other substances not absorbed) |
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how does rifaximin work
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inhibits bacteria that break down protein into smaller absorbable components therefore it keeps protein waste products out of blood
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how does flumazenil work
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BZD antagonist
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if you give flumazenil to a pt and they wake up what does that mean
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that the metabolic waste products are acting on the BZD Rc
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what are coagulopathies
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reduced production of clotting factors and decrease platelet production and function
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what are some things that can cause a decrease in clot factors or decrease in platletts
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decrease in clotting factors due to decreased synthesis by liver
decrease in platelets due to splenomegally storing platelets or consuming alcohol w/ liver disease |
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what can cause hepatorenal syndrome
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vasoconstriction and decrease perfusion (bleeding/hypovolemia) or infection (SBP this is why you give albumin to maintain IV volume), nephrotoxic drugs (AVOID AT ALL COST AMINOGLYCOSIDES, NSAIDS, BECAREFUL W/ ACE-I/ARB AND DIURETICS)
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what type of hepatorenal syndrome will you see a double in SCr within 2 weeks
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TYPE 1 - this has a high mortality rate
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what is the only definitive treatment for hepatorenal syndrome
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transplant
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when do you worry about hepatocellular carcinoma
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once pt develops cirrhosis
fatal without transplantation |
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what is the SCr in pt with liver disease
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its lower than it should be but you must be careful not to over estimate it in pt with ESLD
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what are other antibiotics you can use to tx Encephalopathy
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neomycin
metronidazole |
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what are SE of neomycin
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ototoxicity
nephortoxcity |
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what are SE of metronidazole
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disulfram reaction
metalic taste peripheral neuropathy |
