Term
| Alcoholic Liver Disease (ALD) |
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Definition
progressive, chronic condition due to chronic ingestion of 60-80 g (5-7 drinks) of EtOH daily for long periods of time (5-15 yrs);
- 4 stages:
1) Steatosis - fat accumulation in liver
2) Alcoholic Hepatitis - fibrosis;
3) Alcoholic Cirrhosis - nodular formation;
4) Hepatic Failure |
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Term
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Definition
1st stage in alcoholic liver disease;
- fat accumulates in liver
- occurs in 90% of individuals who consume >60 g EtOH/day;
- occurs w/in a few days of moderate EtOH ingestion;
- reversible --> disappears after 4-6 wks of abstinence;
Most are asymptomatic;
Some: RUQ pain, nausea, anorexia, epigastric discomfort |
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Term
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Definition
Stage 2 in ALD;
- fibrosis or steatonecrosis of liver;
- includes cell injury, necrosis, inflammation, & fibrosis;
- changes in hepatic circulation occur |
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Term
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Definition
Stage 3 in ALD;
- disturbance in liver architecture accompanied by regenerative active;
- nodular formation is seen |
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Definition
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Term
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Definition
| made by documentation of EtOH excess and evidence of liver disease |
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Term
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Definition
| main causes of liver cirrhosis in US |
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Term
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Definition
fatigue, PRURITUS;
hyperpigmentation, jaundice, hepatomegaly, splenomegaly, palmar erythema, spider angiomata, gynecomastia, ASCITES, EDEMA, PLEURAL EFFUSION, respiratory difficulties, malaise, anorexia, weight loss, ENCEPHALOPATHY |
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Term
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Definition
hypOalbuminemia;
elevated PT;
thrombocytopenia (decreased Plts);
elevated ALP;
Elevated AST, ALT, GGT |
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Term
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Definition
most common physical sign of cirrhosis;
Mild to moderately enlarged (12 cm), firm w/ irregular surface;
May be tender;
Due to infiltration, protein accumulation, inflammation, & fibrosis; |
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Term
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Definition
| most marked on extremities, palms & soles --> increased skin bile & concentration |
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Term
| Spider Angiomatas (spider nevus) |
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Definition
small twisted vessels radiate from a red point in the middle;
pressure causes blanching;
seen in face, hands, neck, forearms, upper chest & back |
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Term
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Definition
| red mottling of hands & soles of feet |
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Term
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Definition
| clubbing, flat, white, white bands & brittleness found |
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Term
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Definition
yellow discoloration of skin;
failure to excrete bilirubin |
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Term
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Definition
| ratio of hepatic enzymes that indicates alcoholic hepatitis &/or cirrhosis |
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Definition
| elevated with obstruction |
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Term
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Definition
| due to missing/absent coagulation factors due to damaged liver |
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Term
| Model for End-stage Liver Disease (MELD) Score |
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Definition
used to stratify disease severity & aid in disease prognosis;
Uses pt's bilirubin, SCr, and INR to predict survival;
Higher score = Higher Mortality |
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Term
| Child-Pugh Classification |
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Definition
assesses & defines severity of cirrhosis;
predicts pt survival, surgical outcome, & risk of variceal bleeding; |
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Term
| Common Complications of Cirrhosis |
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Definition
Ascites;
Portal Hypertension (PHT), esophageal varices;
Hepatic Encephalopathy;
Coagulation Disorders |
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Term
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Definition
accumulation of lymph fluid in peritoneal cavity;
Earliest & most common presentation in cirrhosis;
Na & water retention to activate RAAS; |
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Term
| Portal Hypertension (PHT) & Esophageal Varices |
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Definition
elevations in portal BP (>10 mmHg);
also, alternative routes of blood flow which can rupture and cause massive bleeding --> death; |
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Term
| Hepatic Encephalopathy (HE) |
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Definition
toxic metabolites that can reach the brain;
Mainly caused by excess Ammonia (NH3);
Manifests as subtle mental changes to deep coma; |
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Term
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Definition
Tx of severe cirrhosis w/ or w/o HE (MELD >18) and NO C/I to steroids:
- 40 mg/day x 28 days, then 2 wk taper;
Decreases inflammatory cascade;
Improved short-term mortality |
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Term
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Definition
PO PDE inhibitor that inhibits production of TNF-alpha;
Indication: Pts w/ severe cirrhosis C/I to steroid use
Dose: 400 mg PO TID x 4 wks; |
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Term
| Management Approaches to Portal HTN & Variceal Bleeding |
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Definition
**1)Primary Prophylaxis** - prevention of 1st bleeding episode;
2) Tx of acute variceal hemorrhage;
3) Secondary prophylaxis (prevent rebleed) |
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Term
| Primary & Secondary Prophylaxis of Variceal Bleeding |
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Definition
MAINSTAYS: non-selective Beta-Blockers (propanolol or nadolol)
MoA: reduce portal & collateral blood flow decreasing portal vein pressure;
Dosing:
- propranolol 10-20 mg PO TID (10-160 mg BID-TID);
- nadolol 20 mg PO daily (40-120 mg daily); Goal HR: 55-60 bpm
+/-
Nitrates (isosorbide mononitrate) in COMBO w/ beta-blocker for those who do not respond to beta-blocker ALONE;
**Negative effect on long-term survival - use ONLY in pts <50 yrs old**
Dose: isosorbide mononitrate 20 mg PO BID-TID if tolerated |
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Term
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Definition
non-selective Beta-blocker;
Primary & Secondary Prophylaxis of variceal bleeding;
Dose: 10-20 mg PO TID (10-160 mg BID-TID)
**Titrate to a reduction in pulse by 25%
**Goal HR: 55-60 bpm
ADRs:
- fatigue, impotence, bradycardia, dyspnea, depression, HA, hypotension, HF;
C/I: actively drinking, noncompliant pts |
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Term
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Definition
non-selective Beta-blocker used for Primary & Secondary Prophylaxis of Variceal bleeding;
Dose:
- 20 mg PO daily (40-120 mg daily)
**Titrate to a reduction in pulse by 25%
**Goal HR: 55-60 bpm
ADRs:
- fatigue, impotence, bradycardia, dyspnea, depression, HA, hypotension, HF;
C/I: actively drinking, noncompliant pts |
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Term
| isosorbide mononitrate (Imdur) |
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Definition
Indication: used in combo w/ non-selective beta-blocker for prophylaxis of variceal bleeding;
Causes smooth muscle vasodilation & reduction in portal pressure;
**Use only in pts <50 yrs old**
Dosing: 20 mg PO BID-TID if tolerated |
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Term
| Risk Factors for Acute Variceal Hemorrhage |
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Definition
active EtOH abuse;
use of NSAIDs or ASA;
previous variceal hemorrhage; |
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Term
| Initial Treatment Goals for Acute Variceal Hemorrhage |
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Definition
Adequate fluid resuscitation;
Correction of coagulopathy & thrombocytopenia;
Control of bleeding;
Prevention of rebleeding;
Preservation of Liver fcn; |
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Term
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Definition
MoA: mimics naturally-occurring somatostatin --> vasoconstriction --> reduces partial pressure & blood flow;
Similar efficacy to vasopressin;
Rapid onset of action (~15 sec.);
Dose: Bolus of 50-100 mcg, then 25-50 mcg/hr CIV x 5 days |
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Term
| vasopressin (Pitressin, ADH) |
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Definition
**NON-SELECTIVE**
MoA: vasoconstriction --> reduces blood flow & decreases portal pressure --> hemostasis;
Therapeutic doses --> SERIOUS ADRs;
Dose: 0.2-0.4 units/min by continuous peripheral IV, increase to MAX of 0.9 u/min, continue for several hrs if effective & then D/C as bleeding subsides;
ADRs:
- increased BP, arrhythmias, coronary insufficiency, MI, left ventricular failure, GI cramping, bowel infarction, GI necrosis, gangrene, water retention;
Monitor:
- rate of GI bleed
- signs of ischemia
- hypersensitivity rxn
- serum Na |
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Term
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Definition
MoA: vasodilator
Indication: use with VASOPRESSIN** for acute variceal hemorrhage;
Route: IV, SL, patch;
Dose: IV - 40-200 mcg/min initially; MAX = 400 mcg |
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Term
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Definition
excessive accumulation of fluid within peritoneal space;
indicates advanced liver disease & a poor prognosis; |
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Term
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Definition
Abdominal distention (increased girth);
Weight gain (increased fluid retention);
Edema;
Shifting dullness;
Elevation of diaphragm;
Pleural effusion;
Serum & urinary electrolyte abnormalities; |
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Term
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Definition
Abstinence from EtOH;
Sodium restriction to 2,000 mg/day;
Oral diuretic therapy - if tense, a 4-6 L paracentesis should be performed prior to diuretics; |
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Term
| Diuretic Therapy for Tx of Ascites |
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Definition
Single morning doses of:
- Spironolactone 100 mg PO daily AND
- Furosemide 40 mg PO daily
- Goal: 0.5 kg MAX daily weight loss;
- Maintain 100mg:40mg ration (MAX: 400mg:160mg);
Monitor: Wt loss, renal fcn, electrolytes |
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Term
| Parecentesis for Tx of Ascites |
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Definition
Removal of ascitic fluid from peritoneal space;
Small --> diagnostic purposes (50 mL);
Large (LVP) --> therapeutic for tense ascites (5-20 L);
**Use Albumin as volume expander to protect from intravascular depletion if removal amount is >= 5 L; |
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Term
| Diagnosis of Spontaneous Bacterial Peritonitis (SBP) |
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Definition
Absolute PMN count >=250 cells/mm^3;
(+) ascitic fluid bacterial culture;
No evident intra-abdominal, surgically treatable source of infection; |
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Term
| Treatment of Spontaneous Bacterial Peritonitis (SBP) |
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Definition
Empiric Abx therapy initiated;
**- cefotaxime (Claforan) or similar 3rd gen. cephalosporin** - Treatment of Choice --> Dose: 2 g IV q8hr x 5-10 days
Narrow therapy when cultures return; |
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Term
| Prevention of Spontaneous Bacterial Peritonitis (SBP) |
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Definition
Pts who have survived 1 episode:
long-term prophylaxis w/:
- norfloxacin (Noroxin) daily
OR
sulfamethoxazole-trimethoprim 400-80mg (Bactrim SS) daily |
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Term
| Hepatic Encephalopathy (HE) |
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Definition
| a reversible decrease in mental consciousness associated w/ severe liver disease that may range from mild personality changes to a deep coma |
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Term
| Precipitating Events for HE |
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Definition
GI bleeding (increased NH3 production)
Increased dietary protein (increased NH3 production);
Fluid & electrolyte imbalances;
Drugs (sedatives, tranquilizers, analgesics);
Constipation;
Infection & Surgery (increased catabolism, increased nitrogen load); |
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Term
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Definition
disturbances of consciousness - mild lethargy to coma;
personality change - irritability, anxiety, loss of regard for personal appearance;
Intellectual changes - memory loss, inability to concentrate, slurred speech;
Asterixis;
Fetor hepaticus;
Altered sleep-wake cycle; |
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Term
| Protein Restriction in Tx of HE |
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Definition
Limit protein intake in acute dx to 20 g/day until improvement;
Add back to diet in 10-20 g/day increments every 3-5 days to a total of 0.8-1 g/kg/day |
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Term
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Definition
MoA: forms gas --> osmotic diarrhea --> increased excretion of bacteria & soluble nitrogen;
Indication: standard therapy for acute & chronic HE;
Acute Dose: 30-45 mL PO q1-2 hr until laxative effect;
Chronic/Maintenance Dose: 15-30 mL PO 3-4x/day, titrate to 2-4 soft stools/day;
SEs: abdominal discomfort, diarrhea, N/V, hypernatremia;
Precautions: DM, Concomitant meds (Abx, narcotics, anticholinergics, antacids);
Monitor: mental status, asterixis, diarrhea, serum Na |
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Term
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Definition
nonabsorbable oral antibiotic;
MoA: inhibits urease-containing colonic bacteria --> decreasing degradation of protein to NH3;
Dose: 2-8 g/day, give in divided doses QID;
ADRs: ototoxicity, nephrotoxicity |
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Term
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Definition
antibiotic that reduces amount of NH3-producing bacteria in intestine;
As effective as neomycin;
Dose: 250 mg PO TID x 1-2 wks (MAX of 2 wks --> neuropathies);
ADRs: GI limits use;
Monitor:
- mental status
- neuropathies
- diarrhea |
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Term
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Definition
for short-term therapy in refractory HE pts;
MoA: inhibits GABA;
Dose: 0.2-0.15 mg IV |
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Term
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Definition
Nonadsorbable Abx, kills bacteria in gut that produce NH3 & other toxins;
Indication: prevention of HE, ADD to lactulose therapy;
Dose: 550 mg PO BID
VERY expensive |
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Term
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Definition
Goal of Tx is to bring back renal perfusion;
Tx: Hemodialysis (HD) to control azotemia & electrolyte abnormalites;
Albumin infusion + vasoactive drug (octreotide or midodrine);
Expedite referral for liver transplantation; |
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Term
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Definition
1) Abstinence from EtOH;
2) Diet Restrictions:
- Protein: 1 g/kg/day
- Calories: 2000-3000 cal/day
- Sodium: restrict if ascites present
- MVI daily
- Folic acid - 1 mg daily
- thiamine 50-100 mg IV/IM then 50-100 mg PO daily x 1 wk (prevent Wernicke-Korsakoff dx);
- Vit. B12 100-1000 mcg IM monthly
- Vit K 10 mg daily x 3 days if PT is prolonged;
3) Pruritus-associated w/ Jaundice:
- cholestyramine resin (Questran, Cholybar) 4 g resin TID initially x 1-3 wks, administer other meds 1 hr before or 4 hrs after resin; |
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