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Advanced Liver Disease
Overview
50
Audiology
5th Grade
10/19/2013

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Term
injured hepatocytes
Definition
decreased fatty acids metabolism--> fat accumulates; decreased hepatocyte oxygen utilization; increased susceptibility to additional injury
Term
hepatocyte death
Definition
replacement by fibrous tissues = cirrhosis
Term
pathophysiology of cirrhosis
Definition
late stage of progressive hepatic fibrosis; injured hepatocytes; hepatocyte death; irreversible in advance stages ---> only option is liver transplant
Term
liver unable to function enough to prevent systemic symptoms
Definition
decompensated
Term
decreased flow of blood and bile through liver; restricted bile removal = increased bilirubin in blood
Definition
Jaundice
Term
vascular constriction in the liver; portal hypertension = varice formation
Definition
variceal hemorrhage
Term
decreased albumen produced by liver; vascular system unable to maintain osmotic gradient; increased sodium/fluid retention; fluid pools in abdominal cavity
Definition
Ascites
Term
decreased number of functional hepatocytes; decreased blood flow through portal vein -- reduced removal of waste from gut flora; toxins/by products build up in systemic circulation
Definition
encephalopathy
Term
liver function tests
Definition
markers of hepatocyte damage
Term
Hepatocellular
Definition
aminotransferases (ALT; AST)
Term
Obstructive:
Definition
Alkaline Phosphatase and y-Glutamyl Transpeptidase, bilirubin
Term
Thrombocytopenia
Definition
low platelets, or sequestering of platelets
Term
Mayo End-Stage Liver Disease (MELD)
Definition
used for allocation priorities of patients with liver failure; United Network for Organ Sharing; 3 month mortality estimation
Term
Primary PROPHYLAXIS of Portal Hypertension and Variceal bleeding
Definition
Propranolol or Nadolol
Term
DO NOT use these with hemorrhage
Definition
beta blockers
Term
acute blood loss + decreased blood pressure
Definition
= DEAD PATIENT
Term
Acute variceal hemmorrage treatment
Definition
Octreotide bolus + continuous infusion
Term
Octreotide
Definition
somatostatin analog-- splanchnic vasoconstrictor
Term
Vasopressin
Definition
for acute variceal hemorrhage--- associated with higher adverse events (use Octreotide if possible!)
Term
Used in acute variceal hemorrhage for 5-7 days
Definition
Fluoroquinolones (cipro, levo) OR 3rd gen cephalosporin (preferred if high prevalence of E. Coli Fluroquinolone resistance)
Term
Secondary prophylaxis of variceal hemorrhage
Definition
non selective beta blocker + endoscopic band ligation
Term
if unable to do EBL in prevention of recurrent variceal hemorrhage then use ____ (improved median rebleeding rate vs NSBB alone; increased side effect rate)
Definition
isosorbide mononitrate
Term
abdominal pooling of fluid; full "bulging" abdomen; flank dullness, shifting dullness
Definition
Ascites
Term
ascites:
Definition
severe portal hypertension + hepatic insufficiency
Term
splanchnic arterial vasodilation + decreased peripheral resistance
Definition
systemic hypotension
Term
excess renin-angiotensin-aldosterone system activation
Definition
hyperaldosteronism
Term
ascites txt
Definition
sodium restriction; fluid restriction; Spironolactone + Furosemide
Term
rapid relief of ascites --> does not correct underlying problem
Definition
Paracentesis
Term
Spontaneous bacterial peritonitis (SBP)
Definition
infection of ascetic fluid-- translocatin of GI bbacteria
Term
Diagnostic Paracentesis (SBP)
Definition
Polymorphonuclear Leukocyte >/= 250 cells/mm3
Term
signs and symptoms of SBP
Definition
fever, leukocytosis; Abd pain, rebound tenderness, decreased bowel sounds
Term
Spontaneous bacterial peritonitis txt
Definition
3rd gen cephs (Ceftriaxone, Cefotaxime) preferred if prior recent FQ exposure; Fluroquinolones (levofloxacin, Moxifloxacin, Ciprofloxacin); Piperaccilin-tazobactam; Possible ESBL--- use Carbapenem
Term
SBP txt with possible ESBL (Superbug infection--- usually E. Coli + Klebsiella--- resistance to penicillins)
Definition
Use Carbapenem
Term
After 1st episode of SBP, variceal hemorrhage, low protein ascites:
Definition
Fluoroquinalone or TMP/SMX DS PO daily
Term
mental status changes associated with increased ammonia (accumulation in the CNS); cirrhotic liver; produced by GI flora: urease-producing bacteria
Definition
Hepatic encephalopathy
Term
treatment of choice for hepatic encephalopathy
Definition
Lactulose
Term
Lactulose
Definition
decreases ammonia production and increased ammonia elimination
Term
Rifamixin
Definition
alternative/additive therapy to Lactulose; targets gut flora (non-absorbable abx)--- higher dose for traveler's diarrhea
Term
Neomycin
Definition
usually used in combination with lactulose-- ototoxicity and nephrotoxicity
Term
metronidazole
Definition
long term use --> neurotoxicity (alternative in hepatic encephalopathy)
Term
prevention of recurrent hepatic encephalopathy
Definition
protein diet restriction; lactulose, rifamixin; zinc supplementation
Term
severe alcoholic hepatitis +/- encephalopathy
Definition
prednisolone; pentoxifylline
Term
Active metabolite of prednisone; 5 studies show decreased short term mortality compared to placebo; 8 studies showed no effect
Definition
Prednisolone
Term
oral phosphodiesterase inhibitor; 40% in house mortality lower than placebo; no improvement in 2 month survival
Definition
Pentoxifylline
Term
Type 1 hepatorenal syndrome (HRS)
Definition
rapidly progressive; 95% mortality < 1 month if untreated
Term
Type 2 hepatorenal syndrome (HRS)
Definition
slower onset; survival time < 6 months if left untreated
Term
Hepatorenal Syndrome Txts
Definition
Liver +/- kidney transplant; Octreotide + midodrine; albumin; limited studies for vasopressin +/- Octreotide
Term
Liver +/- kidney transplant in HRS
Definition
50-60% 5 year survival rate; Transjugular Intrahepatic Postsystemic Shunt (TIPS) --> 35% 18 month survival
Term
Octreotide + midodrine for HRS
Definition
titrated to increase mean arterial blood pressure at least 15 mmHg
Term
Albumin in HRS
Definition
use high concentration (20-25%) formulation; high cost; combo with octreotide + midodrine loosely 1st line in US
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