Chronic Liver Disease

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Author:
jcu1
ID:
215213
Filename:
Chronic Liver Disease
Updated:
2013-04-23 02:30:35
Tags:
GI
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Description:
Final Exam
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  1. most common cause of CLD
    HBV, HCV, and alcohol abuse
  2. risk factors for CLD
    • regular alcohol intake
    • male
    • >50 yr
  3. clinical complications of decompensated liver failure
    • HE
    • portal htn --> varices and variceal bleeding
    • ascites --> spontaneous bacterial peritonitis
  4. clinical presentation for decompensated liver failure - patient presentation
    • asymptomatic
    • nonspecific (pruritis, dec libido, malaise, dec appetite, weight loss)
  5. clinical presentation for decompensated liver failure - lab results
    • hypoalbuminemia
    • thrombocytopenia
    • inc PT
    • inc alkaline phosphatase
    • inc ALT and AST (<100)
    • inc GGT
  6. clinical presentation for decompensated liver failure - physical exam
    • heptato- and splenomegaly
    • palmar erythema
    • spider angiomata
    • hyperpigmentation
    • gynecomastia
    • jaundice and scleral icterus (later)
  7. Child Pugh grade ranges
    • A: <7 (100% 1 yr survival)
    • B: 7-9 (80% 1 yr survival)
    • C: 10-15 (45% 1 yr survival)
  8. What is the MELD a measure of?
    3 month survival - used to decide of donor livers
  9. 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
  10. 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
  11. lactulose AEs
    • severe diarrhea (excessive dosing)
    • electrolyte imbalance
    • hypovolemia
  12. antibiotics for HE
    • neomycin
    • metronidazole
    • rifaximin
  13. neomycin class/dosing
    • aminoglycoside
    • 1-2 po q6h (liquid or pill) without regard to food
  14. neomycin AEs
    • nephrotoxicity
    • irreversible ototoxicity
  15. metronidazole AEs
    • peripheral neuropathy
    • neurotoxicty with long-term use
    • metallic taste
    • nausea
    • black or brown urine
  16. 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
  17. metronidazole and food
    • without regard to food
    • long acting product w/o food though
  18. metronidazole and pregnancy
    don't take less than 12 wks pregnant or breast-feeding
  19. rifaximin AEs
    • hadache
    • flatulence
    • ab pain
    • constipation
    • n/v
  20. rifaximin DDIs
    none
  21. rifaximin precautions
    • avoid alcohol
    • avoid pregnant/breast-feeding
    • don't take with blood in the stools
  22. other therapies for HE
    • probiotics
    • zinc
  23. combination therapy for HE
    • antibiotics + lactulose
    • probiotics + lactulose
  24. nutrition in HE
    • don't restrict protein
    • goal protein intake 1.2 (1-1.5) g/kg/day
  25. what does an EGD do? who is it preformed on?
    • detects varices and variceal bleeding
    • measures size and appearance
    • all patients with cirrhosis
  26. hepatic vein pressure gradient
    • free hepatic vein pressure - hepatic vein wedge
    • measures intrahepatic vascular resistance due o hepatic infiltration or fibrosis
  27. HVPG > 5
    HVPG > 10
    HVP > 12
    • portal htn
    • significant portal htn
    • associated with risk of developing varices
  28. variceal bleeding risk factor
    • protal htn
    • varix size, appearance, location
    • degree of liver failure (CP class C cirrhosis, ascites, tense ascites)
    • previous variceal bleeding
  29. primary or secondary prophylaxis of variceal hemorrhage
    • nonselective beta-blocker (nadolol, propranolol)
    • endoscopic variceal ligation (EVL)
  30. non selective beta blocker goal
    adjust does to HR of 55-60 bpm
  31. therapy not for primary prophylaxis of variceal bleeding
    • nitrates
    • endoscopic sclerotherapy
    • nonselective beta blocker and EVL combo
    • shunt therapy (TIPS)
  32. secondary prophylaxis of variceal bleeding
    • nonselective beta blocker and EVL combo
    • TIPS or shunt surgery
  33. when to treat variceal bleeding
    • upper GI bleeding PLUS
    • EGD showing (active bleeding varix, "white nipple" varix, clots)
  34. treatment for variceal bleeding
    • octreotide (first line)
    • vasopressin (reserved for serious cases)

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