Liver disease - hepatic enceph, SBP, varices etc.
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| treatment of ascites - diuretics | lasix + spironolactone or amiloride (if gynecomastia). use 40 mg lasix for every 100 mg spironolactone or 10-40 mg amiloride.
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| treatment if tense ascites present | large volume paracentesis - administer albumin if >5L removed at dose of 6-8 g/L of ascitic fluid.
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| what can you add on if refractory ascites | midodrine 7.5 mg TID in addition to standard diuretics
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| goal weight loss in pts with ascites without edema present | 0.5 kg/day - no upper limit if massive edema present
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| theories of hepatic encephalopathy mechanisms | nitrogenous gut byproducts, GABA activation by endogenous BDZ-like substances, zinc deficiency, altered cerebral metabolism
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| classic physical sign of hepatic encephalopathy | asterixis
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| 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
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| 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)
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| ADEs associated with somatostatin and analogs such as octreotide | hyperglycemia, abdominal cramping
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| antibiotic therapy used in esophageal varices | cipro or norfloxacin. can use CTX if resistance to FQs present
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| 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
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| treatment goals of non-selective beta blockers in prevention of variceal bleeding | target heart rate of 55-60 or 25% reduction from baseline.
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| 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.
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| most common bugs in SBP | ecoli or klebsiella. less common strep pneumo or staph aureus
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| 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.
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| 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
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| what antibiotics are recommended for prophylaxis of SBP - both primary and secondary | FQs - cipro or norflox.
bactrim DS 5 times weekly
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| treatment of hepatorenal syndrome | albumin + octreotide and/or midodrine for Type 1. if pt in ICU try albumin and norepi
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| 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
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