Liver Disease and Complications

development Blood shunted

Vasculature
FibrosisScar tissue forms Cirrhosis
regenerative nodules & Portal hypertension
Changes
fibrous bands Arterial vasodiation

Evaluation of Liver Chemistries (ALT/AST):

 Reference Ranges: AST (_______ U/L); ALT (_____ U/L)

Multiple above the ULN Causes

<5 x Nonalcoholic fatty liver disease, alcoholic fatty liver disease, hepatitis B/C,
5-25 x All above causes, hepatitis A
>25x Toxicities, ischemic hepatopathy

Classifications:

1) Model for End-Stage Liver Disease (MELD) - ______________________________________

Calculation: 9.57 x ln(creatinine) + 3.78 x ln(total bilirubin) + 11.2 x ln(INR) + 6.43

2) Child-Pugh Classification – ____________________________

Characteristic Points Assigned

1 point 2 points 3 points Class Score
Encephalopathy (grade) None 1-2 3-4 A 5-6
Ascites None Slight Moderate B 7-9
Albumin (g/dL) >3.5 2.8-3.5 <2.8 C >10
Prothrombin time (seconds prolonged 1-4 4-6 >6
over normal) OR INR <1.7 1.7-2.3 >2.3
Bilirubin (mg/dL <2 2-3 >3

Complications:

Portal Hypertension
Diagnosis Calculate serum-ascites albumin gradient (SAAG); Serum protein minus ascetic
fluid protein. If SAAG >/= _____ g/dL, patient has portal hypertension
Goals Prevent further complications
Treatment Liver transplant
Symptom management
 Ascites
Pathophysiology Increase in portal hypertension (> 12 mmHg)
Goals Decrease abdominal fluid
Prevention Restrict sodium to <2 g/day, Fluid to <1.5 L/day
Stop alcohol consumption
Treatment Diuretics = Lasix _____: Spironolactone ____ (up to _______) PO daily
Midodrine: (A1 agonist): if persistent and hypotensive.
Paracentesis – Give albumin 25% when > _____ removed
TIPs procedure

Gastroesophageal Varices
Pathophysiology Blood flow through liver is blocked; increased pressure in portal vein
Goals Stop bleeding, replenish blood volume, manage blood pressure
Prevention Propranol/Nadolol titrated to HR _______ bpm
Treatment Octreotide 50 mcg bolus followed by 25-50 mcg/hr for 2-5 days
Endoscopy for variceal band ligation
Volume resuscitation
SBP prevention

Spontaneous Bacterial Peritonitis (SBP)

Pathophysiology Bacterial infection due to gram ____________ organisms
Primary Ceftriaxone 1 g IV daily followed by ___________ twice daily for 7 days one
prevention bleeding stops
Secondary Sulfamethoxazole-Trimethoprim 1 DS tablet PO daily OR
prevention Ciprofloxacin 500 mg PO daily
Treatment Ceftriaxone 2 g IV daily OR cefotaxime 2 g IV every 8 hours for 5-7 days

Hepatic Encephalopathy
Pathophysiology Accumulation of toxins in the brain
Goals Decrease ammonia to resolve altered mental status
Prevention Lactulose 30-45 mL (20-30 g) PO 2-4 times per day titrated to 2-3 soft BM
Rifaximin 550 mg PPO BID
Treatment Lactulose 30-45 mL (20-30 g) PO every 1-2 hours titrated to 2-3 soft BM

Hepatorenal Syndrome
Pathophysiology Increase in renal vasoconstriction involving circulatory failure
Goals Decrease splanchnic vasodilation
Prevention Prevent progression
Treatment Liver transplant
Albumin 1g/kg (max 100g) IV x 1 then 20- 60 g IV daily
Midodrine 5-15 mg PO q8h
Octreotide 100-200 mcg SQ q8h