Notes in cirrhosis

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Published	09/08/2024	cirrhosis is distinguished as either {{c1::compensated}} or {{c1::noncompensated}}
Published	09/08/2024	{{c1::compensated cirrhosis}} is when the liver can still perform functions
Published	09/08/2024	{{c1::Decompensated cirrhosis}} is when the liver is unable to perform functions
Published	09/08/2024	decompensated cirrhosis will have {{c1::variceal hemorrhage, ascites, encephalopathy, jaundice}}
Published	09/08/2024	the Child-Pugh Classification classifies the severity of cirrhosis by the presence of {{c1::encephalopathy}}, {{c1::ascites}}, {{c1::bilirubin}} level…
Published	09/08/2024	class A ({{c1::5-6}}) of child-pugh is {{c2::well compensated}}
Published	09/08/2024	Class B ({{c1::7-9}}) is considered {{c2::significant comprise}} on the CP Classification
Published	09/08/2024	Class C {{c1::10 or more}} is considered {{c2::decompensated}} on the CP classification
Published	09/08/2024	Model for End-Stage Liver Disease (MELD) is a {{c1::prognostic}} calculation for 3 month {{c1::mortality risk}}
Published	09/08/2024	Original or MELD-Na (incorporates sodium): ranges from {{c1::6-40}}, higher number indicates {{c1::more severe}} disease
Published	09/08/2024	UNOS modification: original MELD with limits set on entered lab values, analyze {{c1::transplant eligibility}}
Published	09/08/2024	Portal HTN is caused by an increased {{c1::intrahepatic resistance}} caused by liver {{c1::fibrosis}}, drives a lot of cirrhotic complications be…
Published	09/08/2024	as chronic liver disease progresses, {{c1::portal pressure}} increases and {{c2::hyperdynamic circulation}} begins and increases; {{c3::varices}} begi…
Published	09/08/2024	causes of cirrhosis are {{c1::alcoholism, viral hepatits, nonalcoholic fatty liver diseae (NASH), bile duct disease, genetic disorders }}
Published	09/08/2024	complicatoins of cirrhosis are {{c1::VH, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome (HRS) }}
Published	09/08/2024	{{c1::gastroesophageal varices}} (bulges of blood vessels) present in 50% of pts with cirrhosis. The bulges can rupture and cause {{c1::variceal heorr…
Published	09/08/2024	an increased resistance of blood flow through the portal system leads to {{c1::esophageal varices}} which lead to {{c1::variceal hemorrhages }}
Published	09/08/2024	{{c2::Non selective beta blockers (NSBB)}}  reduce {{c1::portal pressure}} by: reducing {{c3::cardiac output}} via B1 receptors and producin…
Published	09/08/2024	adverse effects of NSBB beta-blockers is FIHBB {{c1::bronchoconstriction, hypotension, bradycardia, fatigue, impotence}}
Published	09/08/2024	goal of NSBB is to titratre to goal {{c1::heart rate of 55-60 bpm}} or a {{c1::25% reduction from baseline}}
Published	09/08/2024	NSBBs used for prevention of VH are {{c1::propranolol}} and {{c2::nadolol}}
Published	09/08/2024	{{c1::propranolol}} is 20mg PO 2x daily while {{c1::nabodol}} is the same once daily
Published	09/08/2024	if a patient has cirrhosis WITHOUT varices, NSBBs are {{c1::NOT recommended}} and an EGD should be repeated in 3 yers
Published	09/08/2024	if a patient has SMALL varices that have not bled and have a high child-pugh score, NSBBs are {{c1::recommended }}
Published	09/08/2024	if a patient has SMALL varices that have NOT bled and have a LOW child-pugh score, NSBBs are {{c1::considered}}
Published	09/08/2024	if a patient has medium or large varices that have not bled and have a high child-pugh score, NSBBs or {{c1::an EVL}} are {{c1::recommended }}
Published	09/08/2024	if a patient has medium or large varices that have not bled and have a LOW child-pugh score, NSBBs are {{c1::preferred}} and an EVL is {{c1::2nd …
Published	09/08/2024	NSBBs are used for {{c1::Primary and secondary prevention of variceal hemorrhage (VH)}}
Published	09/08/2024	acute management of Variceal Hemorrhages: 1. {{c1::volume repletion (fluids)}}2. {{c1::vasoconstrictors     - octreotide infusion …
Published	09/08/2024	{{c1::Endoscopic variceal litigation (EVL)}} is when an interventionalist with a scope puts rubber bands over varices and prevents a bleedd/ treats it…
Published	09/08/2024	{{c1::octerotide}} and {{c1::vasopression }} are vasoconstrictors
Published	09/08/2024	{{c1::Octerotide}} is the first line vasoconstrictor for acute management of VH and is also used for hepatorenal syndrome
Published	09/08/2024	{{c1::Vasopressin}} is the 2nd line vasoconstrictor for acute management of VH
Published	09/08/2024	{{c1::Octerotide }} inhibits release of {{c3::vasodilator hormones}} which leads to {{c2::splanchnic vasoconstriction}} and decreases {…
Published	09/08/2024	{{c1::vasopressen }} {{c3::constricts}} {{c2::mesenteric arterioles}} and {{c3::decreases}} {{c2::portal venous flow}}
Published	09/08/2024	hyperglycemia, chest pain, fatigue/headache, GI upset, pruritus are SEs of {{c1::octerotide}}
Published	09/08/2024	hypertension, severe headache, coronary ischemia, myocardial infarction are SEs of {{c1::Vasapressin}}
Published	09/08/2024	duration of vasoconstrictors for VH is {{c1::3-5 days}}
Published	09/08/2024	prophylactic antibiotics are used to prevent {{c1::translocation of the bacteria}} to other parts of the body
Published	09/08/2024	{{c1::Transjugular intrahepatic portal systemic shunt (TIPS}}) is a stent placed between the IVC and portal vein to allow blood to flow through the li…
Published	09/08/2024	secondary prevention of VH is for patients who {{c1::have surived one episode of VH}} or who {{c1::experience recurrent VH despite pharm therapy and E…
Published	09/08/2024	secondary prevention for patients who survived one episode of VH and have any bleeding risk should have a {{c1::combo of NSBB plus EVL}}. The {{c1::EV…
Published	09/08/2024	secondary prevention for patients who have RECURRENT VH and have a MODERATE bleeding risk should have {{c1::TIPS considered}}
Published	09/08/2024	{{c1::ascites}} is the accumulation of free fluid in the peritoneal cavity due to {{c2::increased resistance}} within the liver (forces lymphatic…
Published	09/08/2024	{{c1::albumin}} is responsible for osmotic pressure within the bloodstream and when levels of {{c1::albumin}} are low, it can make your vessels more l…
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Published	09/08/2024	•~50% of patients with cirrhosis will develop {{c1::ascites}} within first decade of diagnosis and 15% of patients with it will die in …
Published	09/08/2024	first line management of ascites is: 1. {{c1::sodium restriction (<2 g/day)}} 2. {{c1::diuretics     - aldosterone antagonist: …
Published	09/08/2024	2nd line management of ascites is: 1. {{c1::treatment     - serial therapeutic paracentesis AND 25% albumin   &nbs…
Published	09/08/2024	{{c1::spironolactone (aldactone)}} is th aldosterone antagonist of choice for treating ascites
Published	09/08/2024	{{c1::furosemide (Lasix)}} is the loop diuretic of choice for treating ascites
Published	09/08/2024	sprionolactone inhibits {{c1::K+ exchange}} at {{c1::distal renal tubule}} and increases {{c2::sodium}} and {{c2::water excretion}}
Published	09/08/2024	furosemide inhibit {{c1::Na+/Cl- absorption}} at {{c2::ascending Loop of Henle}}
Published	09/08/2024	Hyperkalemia , gynecomastia are SEs of {{c1::spironolactone}}
Published	09/08/2024	hypo –Na, -K, Ca and –Mg; gout, dehydration are SEs of {{c1::furosemide}}
Published	09/08/2024	{{c1::spironolactone}} is given in combo with {{c1::loop diuretic}} to nullify effects on {{c3::potassium}} when treating {{c2::ascites}}
Published	09/08/2024	Refractory Ascites is ascites that cannot be mobilized despite of {{c1::sodium restricted diet}} and {{c1::high dose diuretics}} a…
Published	09/08/2024	{{c1::Colloid}} is used as fluid and albumin replacement because it increases {{c2::oncotic pressure}} which increases in intravas…
Published	09/08/2024	•Following Paracentesis (≥5 liters) •give {{c1::25% Albumin}} •Dose: {{c2::5-8 g/L of fluid removed}} •Administer soon after procedure to av…
Published	09/08/2024	{{c1::Spontaneous Bacterial Peritonitis (SBP)}} is infection of ascitic fluid without an apparent intra-abdominal source most commonly caused by&…
Published	09/08/2024	Spontaneous Bacterial Peritonitis  (SBP) is confirmed by the presence of >250 {{c1::polymorphonuclear neutrophils(PMNs)/mm3}} in abs…
Published	09/08/2024	{{c1::SBP}} is associated with 20%–40% of in-hospital mortality and patients should be considered for liver transplants
Published	09/08/2024	Ceftriaxone and Cefotaxime are the preferred {{c1::antibiotics}} for SBP but Levofloxacin and Ciprofloxacin can be used …
Published	09/08/2024	{{c2::albumin}} helps reduce renal complications such as {{c3::hepatorenal syndrome}} in SBP and reduces {{c4::mortality}} in patients that have incre…
Published	09/08/2024	treat SBP with {{c1::antibiotics}} for 5 days and {{c1::albumin}} for day 1 and day 3
Published	09/08/2024	Primary prevention of SBP in the setting of acute upper GI bleed is given for 7 days to prevent {{c1::bacterial translocation}}
Published	09/08/2024	for primary prevention of SBP, {{c1::long term antibiotics}} are indicated in patients with ascitic fluid protein (<1.5 g/dL) + renal dys…
Published	09/08/2024	{{c1::antibiotics }} are 1st line SBP prophylaxis choice
Published	09/08/2024	Secondary prevention of SBP is after a SBP event (recurrence is 70% in 1 year) and pt will be on the meds {{c1::indefinitely }} which are:{{c2:: …
Published	09/08/2024	primary management of SBP is:1. {{c1::start abx promptly     - preferred         - Cefotaxime  …
Published	09/08/2024	{{c1::Hepatorenal Syndrome (HRS)}} is decreased {{c2::renal perfusion}} due to vasodilation resulting in renal failure; kidneys ar…
Published	09/08/2024	Hepatorenal Syndrome (HRS) is a diagnosis of {{c1::exclusion }}
Published	09/08/2024	•Type {{c1::1}} HRS:  •More severe •Acute •Rapid Progression (<2 weeks) •SCr doubles (>2.5) or CrCl decreases by 50% (< 20ml…
Published	09/08/2024	•Type {{c1::2}} HRS: •Slow Progression (weeks to months) •Chronic •Monitoring, not much more you can do
Published	09/08/2024	Management of HRS:Avoid {{c1::excess fluid}} (volume overload / hyponatremia){{c2::Albumin}} 1g/kg/day (try to get some intravascular volume back) AND…
Published	09/08/2024	{{c3::beta-blockers}} are {{c1::not indicated}} in {{c2::early cirrhosis}} because it may increase adverse effects. They may only be indicated fo…
Published	09/08/2024	The "window open" refers to when {{c1::beta blockers are indicated in cirrhosis. }}
Published	09/08/2024	the "window closes" refers to when {{c1::beta-blockers are contraindicated}} which is under the following situations:
Published	09/08/2024	Hepatic Encephalopathy (HE):Decreased {{c1::hepatic function / sunting}} → accumulation of  {{c2::nitrogen substances}} → substances invade …
Published	09/08/2024	Hepatic Encephalopathy (HE): Central nervous system disturbances with a wide range of {{c1::neuropsychiatric}} symptoms associated with {{c2::hepatic …
Published	09/08/2024	Management of HE:1.{{c1::Supportive care}}2. {{c1::Treat / remove precipitating factors}}: constipation, GI bleeding, infection, hypokalemia, dehydrat…
Published	09/08/2024	Lactulose's MOA: {{c1::non-absorbable}} disaccharide that lowers {{c1::colonic pH}} and {{c1::cathartic effect}}
Published	09/08/2024	{{c1:: Lactulose}}SE's are Abdominal pain, diarrhea
Published	09/08/2024	Monitor for {{c1::mental change}} and NOT {{c1::ammonia}} levels when administering {{c2::lactulose }}
Published	09/08/2024	{{c1::rifaximin and neomycin}} are antibiotics used to treat HE
Published	09/08/2024	Ceftriaxone and Ciprofloxacin are {{c2::antibiotics}} used for acute management of {{c3::VH }}
Published	09/08/2024	{{c1::Spontaneous Bacterial Peritonitis}} (SBP)
Published	09/08/2024	lactulose is used to treat {{c1::hepatic encephalopathy}}
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