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18 Cards in this Set
- Front
- Back
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Class the following complications of cirrhosis as either "portal HTN" or "Hepatic insufficiency":
Varicies Coagulopathy Hepatorenal syndrome Jaundice/pruritus Ascities/SBP |
Portal HTN
- Ascities/SBP - Hepatorenal - Varicies Hepatic insufficiency = the others. |
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"end-stage liver dz" and "chronic liver failure" are synonyms for what?
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cirrhosis
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What is the definition of portal HTN? When do complications arise?
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portal hepatic vein pressure (PHVG) > 5 mmHg; complications typically arise when PHVG > 10-12 mmHg
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Define ascities.
How does it happen? |
abnormal accumulation of fluid in the abdominal cavity
Hydrostatic backup, lymph overproduction, and low oncotic pressure might contribute. |
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Are there any contraindications to a diagnostic paracentesis for ascities? What should you make sure to avoid?
What tests might you send on the collected fluid? How do we decide if the ascities is from portal HTN? |
not really, no.
the spleen. - cell count and differential - culture - albumin - Total protein Might also do: - Amylase, LDH, glucose, triG - Gram stain, TB smear/culture - Cytology Serum-Ascites albumin gradient Alb(serum) - Alb(ascites) - >/= 1.1g/dL (high).... think cirrhosis, alcoholic hepatitis, etc. - low... something else, bilary leak, carcinoma, etc. |
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When > 250 PMNs in ascitic fluic, what is the Dx? do you need to confirm with culture results?
Tx? |
Spontaneous Bacterial Perotonitis (SBP)
No. 3rd gen cephalosporin, as well as fluid expanders (albumin). |
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Intial tx for ascites? Refractory Ascites?
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Initial:
- Na restriction - diuretics - large volume paracentesis Refractory: - large volume paracentesis - Peritoneovenous shunt (old tx) - TIPS (transjugular intrahepatic portosystemic shunt) - Liver Txplt |
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What else can TIPS be used for? Complications of the procedure?
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refractory ascities, hepatic hydrothorax, variceal bleeding
Procedural Encephalopathy Shunt stenosis or occlusion |
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Is Ascites (from liver dz) a good or bad prog marker?
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Bad. Mean survival ~1.5y
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What is the only identified cause of Hepatorenal syndrome?
It is pathophysiologicallly linked with which other complication of cirrhosis? Explain why HRS is a functional disorder? |
Renal failure in the setting of cirrhosis and portal hypertension
Ascites The kidneys are only working strangely b/c of circulating hormonal factors ... putting them in someone else, or getting a new liver for the pt will fix them. |
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How do we treat HRS?
W/o reversal, what is the prog? |
Exclude other causes of renal failure
Avoid nephrotoxic agents Restrict sodium and water Establish circulatory volume (albumin) Treat hemodynamics: correct peripheral vasodilation (terlipressin) other vasoconstrictors (octreotide; midodrine) very bad. |
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If a pt has acute renal failure, and the Na is <10mEq/L, what do we run next? >30mEq/L, what do we Dx?
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CVP: <5mmHg --> "pre-renal" azotemia
>10mmHg --> HRS ATN |
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What is the main concern with varices?
Tx? |
Bleeding --> exsanguination
Bleeding --> aspiration --> pneumonia --> combo medical & endoscopic treatment Stabilize patient secure airway if necessary fluid resuscitation/blood transfusion correct coagulopathy Medical therapy somatostatin or octreotide – initial therapy! (historical: vasopressin; nitroglycerin) proton-pump inhibition antibiotics - don't stop the bleeding, but do improve survival for after the varices have been fixed. Endoscopic ligations ("banding") |
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How do we try to prevent varices?
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Beta-blocker
Preventative Endoscopic Ligation TIPS Liver Txplt Rare: Surgical Shunt |
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syndrome of impaired brain function due to liver failure.... this defines what cirrhotic complication?
- features? - root causes? (2 hypothesized) Is it caused by cerebral edema? |
Hepatic encephalopathy
- reversible neuropsychiatric abnormalities - Asterixis - Hepatic failure (toxins not being metabolized - Portosystemic shunting (toxins being shunted around liver) No, unlike ARF's complication. |
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Which of the following can precipitate Hepatic encephalopathy's more acute deterioration in a pt with liver dz?
Alcohol Infections (remember SBP) GI bleed Medications (sedatives/hypnotics; diuretics) Renal failure (HRS or otherwise) Myocardial infarction Hepatocellular carcinoma Surgery TIPS Progression of underlying liver disease |
all of 'em can.
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Tx for Hepatic Encephalopathy?
How might we change their diet? |
reverse underlying cause
lactulose: traps ammonia in the gut lumen antiB Protein restriction branched chain amino acid supplementation Liver Txplt |
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What determines the pt's placement on the liver txplt list?
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How sick they are --> MELD score.
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