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Cirrhosis - facts
- D: C liver dz- fibrosis, disrupt liver arch, //nodules; irreversible
- I: blood flow->portal HTN
- xBiochem fns (Alb & clot fact synth)
- -> ascites,periph edema,splenomeg
- C: EtOH liver dz (10-15%)
- C Hep B/C
- Drugs- APAP tox, methotrexate
- AI, prime/2nd biliary cirrhosis
- Inher metab dz- hemochrom,Wilson
- Cong 2/2 R HF, constrict pericard
- α-antitrypsin def; NASH
- hep veno-occl dz (post BMT)
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Cirrhosis - S/Sx
- Early: Asympt
- PHTN: ascites,varices,hemor,edema,SM
- Sex: gynecomastia, testic atrophy
- Derm: palm eryth, spid ang, caput med
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Child-Turcotte-Pugh score
- Meas cirrhosis sev, predict morb/mort
- _ 1 2 3 _
- Enceph None MildCtl Advnc
- Ascites None MildCtl PoorCtl
- T. Bili <2.0 2-3 >3.0
- Album >3.5 2.8-3.5 <2.8
- PT/INR<1.7 1.7-2.3 >2.3
- Survival%
- Class points 1yr 2yr
- A 5- 6 100 85
- B 7- 9 81 57
- C 10-15 45 35
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Cirrhosis - portal HTN - S/Sx
- splenomegaly
- ascites
- varices->bleed
- hepatic encephalopathy
- caput medusa
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Cirrhosis - portal HTN - Dx
- S/SXs
- Paracentesis
- Thromocytopenia, leukopenia
- Doppler US, CT/MRI
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Cirrhosis - portal HTN - Tx
- Specific complication: treat
- Vasoconstr: splanch&portal ven flow vasopressin,somatostatin,non-select BB
- Vasodil: alter inter-hep resist NTG, long-acting NO3s, prazoin
- TIPS: transjug intrahep port-sys shunt
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Cirrhosis - varices - S/Sx
- Caput medusae: disten abd wall veins
- Rectal: hemorrhoids
- GI: Esoph 90%, Gastr 10%
- //bleed,/enceph,fatigue,pallor,tachy
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Cirrhosis - varices - Dx
- Hepatic venous pressure gradient
- /INR
- TCP
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Cirrhosis - varices - Tx
- PPx: ~sel BB (propanolol,nad-,tim-)
- Init: Hemodyn stabl (IVF)
- IV abx: PPx ~SBP
- IV octreotide: 3-5d
- UGI endo: emergent
- Varices: ligat'n, band, sclero, octre, balloon tamp,TIPS,shunts,liv Xplant
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Cirrhosis - ascites - etiology
- E: PHTN & HoAlb
- DDx: cirrh, CHF, C renal dz, //fluid, TB, malig, HoAlb, liver aldo inactiv
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Cirrhosis - ascites - S/Sx
- Abd dist,fluid wave,shift dull (>1.5L)
- /wt,early satiety,SOB,hernias evident
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Cirrhosis - ascites - Dx
- Abd US: >30mL, conf PHTN/splenomeg
- paracent: SBC,RBC,cx,alb,Gr,LD,TG,cyt
- infectn >=250 pmn/mm3
- PHTN - SAAG>1.1 g/dL
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Cirrhosis - ascites - Tx
- Bed rest, Na, dour (furos+spiron)
- Paracentesis, therapeutic
- TIPS (effective 90%, improve 3 mo)
- Liver Xplant (w/o 75% mort if refract)
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Cirrhosis - hep enceph - facts
Toxic metabolites reach brain (50%)
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Cirrhosis - hep enceph - precip
- Alkalosis
- HoK (2/2 diur)
- Sedating drugs (narc,tranq,sed,sleep)
- GI bleed
- Syst infection
- Surg
- HoVol, HoNa, Hypoxia
- N-load (GI bleed, /prot, azot, constip)
- A liver progression, superimposed
- Portal-systemic shunts
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Cirrhosis - hep enceph - S/Sx
- ment fn,confus,poor conc,stupor/coma
- Asterixis (flapping tremor)
- Rigidity, HReflexia
- Fetor hepatics (must odor of breath)
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Cirrhosis - hep enceph - Dx
- /NH3
- HGammaglob
- TCP, LeukoP, PCP
- /CSF glutamine
- CT/MRI - cortical atrophy(basal ganglia)
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Cirrhosis - hep enceph - Tx
- Exclude other causes, ID precip factors
- Lactulose (prevent NH3 absorb)
- Bowel cleanse (enema, gastric lavage)
- Neomycin (kills bowel flora->NH3)
- Protein restrict (1g/kg/day), veggies
- Rifaxamin
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Cirrhosis - hepatorenal synd.
- Indicates: ESLD
- Cause: progressive RF 2/2 HoPerfus'n
- Precip: Infect, diur, LV paracentesis
- Sx: azot(/BUN:Cr), oliguria, HoNa, HoTN, urine Na(<10), GFR
- Tx: liver Xplant
- Prev: paracentesis+alb
- SBP- Alb+cefotaxime
- EtOH hep- pentoxifylline
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Cirrhosis - SBP - acronym
Spontaneous Bacterial Peritonitis
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Cirrhosis - SBP - facts
- Infected ascetic fluid (in 20% hosp'd)
- ESLD, high mort (20-30%), ?ascites
- High recur (70% 1st yr)
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Cirrhosis - SBP - agents
- E. coli MC
- Klebsiella
- S. pneumo
- single org
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Cirrhosis - SBP - S/Sx
- F, Abd P, AMS
- N/V, rigors, D, hep enceph, malaise
- HoTN, tachycardia
- Rebound tenderness
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Cirrhosis - SBP - Dx
- Azotemia: /Urea, Cr
- Paracen: WBC>500,PMN>250,GS?Cx(-)
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Cirrhosis - SBP - Tx
- Start b4 Cx results if PMN>250cells/mL
- 1st: broad spect abx - 3G ceph or FQs
- cefotaxime, ceftazidime
- Improve: 24hrs; repeat paracent 2-3d
- PPx: prior SBP, GI bleed, TProt<1g/dL
- norfloxacin, levo- (risk UTI/resist)
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Cirrhosis - hyperestrinism
- D: excessive secr estrone,estadiol,estriol
- Sx: spider ang, palm eryth, gynecom, testicuar atrophy
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Cirrhosis - coagulopathy
- 2/2: synthesis of clotting factors
- /PT: (prothrombin time), /PTT if severe
- Vit K: ineffective (dz liver can't use it)
- Tx: FFP
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Cirrhosis - hepatocellular carcinoma
HCC - present in 10-15%
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Cirrhosis - Tx
- Underly dz: xEtOH, interferon Hep B/C
- Avoid: APAP, EtOH (cause liver inj)
- Compl: varic bleed,ascites,hep enceph
- Xplant: only hope for cure (xEtOH 6mo)
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