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BCPS study guide

Liver disease - hepatic enceph, SBP, varices etc.

treatment of ascites - diuretics lasix + spironolactone or amiloride (if gynecomastia). use 40 mg lasix for every 100 mg spironolactone or 10-40 mg amiloride.
treatment if tense ascites present large volume paracentesis - administer albumin if >5L removed at dose of 6-8 g/L of ascitic fluid.
what can you add on if refractory ascites midodrine 7.5 mg TID in addition to standard diuretics
goal weight loss in pts with ascites without edema present 0.5 kg/day - no upper limit if massive edema present
theories of hepatic encephalopathy mechanisms nitrogenous gut byproducts, GABA activation by endogenous BDZ-like substances, zinc deficiency, altered cerebral metabolism
classic physical sign of hepatic encephalopathy asterixis
antibiotics for treatment of hepatic encephalopathy and concerns associated with each neomycin - concern for renal insufficiency metronidazole - can cause peripheral neuropathy rifaximin - expensive but best tolerated
drug therapy options to control variceal bleeding and proposed MOAs vasopressin (splanchnic vasoconstriction) + nitroglycerin (attenuation of coronary vasoconstriction and hypertension) octreotide or somatostatin (reduce portal pressure via vasoactive peptides like glucagon inhibition or via localized vasoconstriction)
ADEs associated with somatostatin and analogs such as octreotide hyperglycemia, abdominal cramping
antibiotic therapy used in esophageal varices cipro or norfloxacin. can use CTX if resistance to FQs present
role in therapy for variceal bleeding: non-selective beta blockers for primary prophylaxis NOT for treatment. can be used if increased risk of bleeding such as child Pugh B OR c, RED WALE MARKS ON VARICES. and SMALL VARICES AND NO HX OF BLEEDING
treatment goals of non-selective beta blockers in prevention of variceal bleeding target heart rate of 55-60 or 25% reduction from baseline.
secondary prophylaxis options for variceal bleed endoscopic band ligation + non-sel. beta blockers. may add nitrate but no improved mortality and increased ADEs. lower bleed risk though. TIPS for refractory pts.
most common bugs in SBP ecoli or klebsiella. less common strep pneumo or staph aureus
diagnostic criteria for SBP with abdominal paracentesis PMN >250 cells/mm^3, lactate dehydrogenase, glucose and protein values may help to determine from secondary perotinitis. fluid typically culture positive ~67% but gram stain usually negative.
when is albumin replacement indicated along with antibiotics in patients with SBP if Scr >1mg/dL, BUN >30 mg/dL or total bili >4 mg/dL
what antibiotics are recommended for prophylaxis of SBP - both primary and secondary FQs - cipro or norflox. bactrim DS 5 times weekly
treatment of hepatorenal syndrome albumin + octreotide and/or midodrine for Type 1. if pt in ICU try albumin and norepi
criteria for steroid treatment in pts with alcoholic liver disease and proposed dosing MDS score >32 or MELD >18 - give 4 wk course of prednisolone 40 mg QD f/b 2 wk taper
Created by: mjuhlin