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jcu1
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most common cause of CLD
HBV, HCV, and alcohol abuse
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risk factors for CLD
- regular alcohol intake
- male
- >50 yr
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clinical complications of decompensated liver failure
- HE
- portal htn --> varices and variceal bleeding
- ascites --> spontaneous bacterial peritonitis
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clinical presentation for decompensated liver failure - patient presentation
- asymptomatic
- nonspecific (pruritis, dec libido, malaise, dec appetite, weight loss)
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clinical presentation for decompensated liver failure - lab results
- hypoalbuminemia
- thrombocytopenia
- inc PT
- inc alkaline phosphatase
- inc ALT and AST (<100)
- inc GGT
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clinical presentation for decompensated liver failure - physical exam
- heptato- and splenomegaly
- palmar erythema
- spider angiomata
- hyperpigmentation
- gynecomastia
- jaundice and scleral icterus (later)
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Child Pugh grade ranges
- A: <7 (100% 1 yr survival)
- B: 7-9 (80% 1 yr survival)
- C: 10-15 (45% 1 yr survival)
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What is the MELD a measure of?
3 month survival - used to decide of donor livers
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pathogenesis of HE in LD
- NH3 isn't converted to urea or used to convert glutamate to glutamine so that it is redirected to the brain
- accumulates there
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first line in HE therapy (acute and chronic)
- Lactulose 20g/30ml solution
- acute: start with 45 mL po q1h until evacuation, then 15-45 ml bid or tid
- chronic: 30-45 ml po bid-qid
- titrate to 2-4 semi-soft stools daily
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lactulose AEs
- severe diarrhea (excessive dosing)
- electrolyte imbalance
- hypovolemia
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antibiotics for HE
- neomycin
- metronidazole
- rifaximin
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neomycin class/dosing
- aminoglycoside
- 1-2 po q6h (liquid or pill) without regard to food
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neomycin AEs
- nephrotoxicity
- irreversible ototoxicity
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metronidazole AEs
- peripheral neuropathy
- neurotoxicty with long-term use
- metallic taste
- nausea
- black or brown urine
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neomycin precautions
caution in pts with ear probs, kidney disease, parkinsons, other nerve probs
don't take in Crohn's disease, ulcerative colitis or intestinal obstruction
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metronidazole and food
- without regard to food
- long acting product w/o food though
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metronidazole and pregnancy
don't take less than 12 wks pregnant or breast-feeding
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rifaximin AEs
- hadache
- flatulence
- ab pain
- constipation
- n/v
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rifaximin precautions
- avoid alcohol
- avoid pregnant/breast-feeding
- don't take with blood in the stools
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combination therapy for HE
- antibiotics + lactulose
- probiotics + lactulose
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nutrition in HE
- don't restrict protein
- goal protein intake 1.2 (1-1.5) g/kg/day
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what does an EGD do? who is it preformed on?
- detects varices and variceal bleeding
- measures size and appearance
- all patients with cirrhosis
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hepatic vein pressure gradient
- free hepatic vein pressure - hepatic vein wedge
- measures intrahepatic vascular resistance due o hepatic infiltration or fibrosis
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HVPG > 5
HVPG > 10
HVP > 12
- portal htn
- significant portal htn
- associated with risk of developing varices
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variceal bleeding risk factor
- protal htn
- varix size, appearance, location
- degree of liver failure (CP class C cirrhosis, ascites, tense ascites)
- previous variceal bleeding
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primary or secondary prophylaxis of variceal hemorrhage
- nonselective beta-blocker (nadolol, propranolol)
- endoscopic variceal ligation (EVL)
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non selective beta blocker goal
adjust does to HR of 55-60 bpm
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therapy not for primary prophylaxis of variceal bleeding
- nitrates
- endoscopic sclerotherapy
- nonselective beta blocker and EVL combo
- shunt therapy (TIPS)
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secondary prophylaxis of variceal bleeding
- nonselective beta blocker and EVL combo
- TIPS or shunt surgery
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when to treat variceal bleeding
- upper GI bleeding PLUS
- EGD showing (active bleeding varix, "white nipple" varix, clots)
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treatment for variceal bleeding
- octreotide (first line)
- vasopressin (reserved for serious cases)
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