Cirrhosis and Pancreatitis

• Backup in a portal vein causes an increase in pressure
• Decreased NO causes decreased vasodilation, adding to the pressure
• Increased endothelin causes increased vasoconstriction, adding to the pressure
• Fluid then starts to be forced into the abdominal cavity through leaky blood vessels

• Inflammation of the liver leads to fibrosis, which leads to cirrhosis
• Cirrhosis causes impaired blood flow, which leads to portal HTN

• Blocked flow, decreased NO, and increased endothelin add to pressure
• Increased pressure adds to ascites
• Ascites leads to a decrease in effective intravascular volume, CO, and renal perfusion
• RAAS is turned on by low volume and decreased renal perfusion
• Sodium and water are retained to increase volume
• This retention increases the pressure and around and around we go!

increase in ammonia, mercaptans, short-chain fatty acids, and phenol due to decreased ability of the cirrhotic liver to detoxify them

• confusion
• forgetfulness
• irritability
• sedation
• asterixis ("liver flap" of the hands)
• coma

• Remove sedating drugs
• Treat infection
• Limit dietary protein to 1.5-2.2g/kg/d
• Fix GI bleed (breaks down to ammonia in the gut, adding to problem)
• Prevent overdiuresis (can cause alkoalosis which increases ammonia and other amines in the brain)
• Treat constipation

• Lactulose (DOC)
• Neomycin
• Lactulose + Neomycin

• Metabolized to lactic, acetic, and formic acid
• Acid plus colonic NH3 = NH4+ which cannot get back into the blood so it passes with the stool

• Kills urea splitting bacteria
• Can't make ammonia without splitting urea

• Diarrhea (SE and therapeutic goal → these pts should have 2-4 loose stools/d)
• Mental status and connect the number test
• Renal function (Neomycin)
• Ototoxicity (Neomycin)

• Octreotide (DOC): vasoconstriction
• Vasopressin: more vasoconstriction, but more SE (ischemia, ↓CO, gangrene)
• Balloon tamponade
• Portosystemic shunt

• Propranolol (DOC): low dose, titrate to pulse of 55-60 or 25% reduction
• Isosorbide mononitrate: vasodilation of veins
• Propranolol + Isosorbide mononitrate: better than either alone
• Scleropathy
• Variceal ligation (banding)

Diuretics increase excretion of sodium which will help overcome the retention caused by the RAAS activation, but you don't want to get rid of all of your potassium and go hypokalemic

• Spironolactone
• Eplerinone
• Both are DOC, but spironolactone causes gynecomastia
• Furosemide (if impatient)
• Paracentesis + infusion of albumin
• TIPS

• Aldosterone antagonist: aim for 1L/d urine output with peripheral edema; 0.5L/d if no edema (don't want to go too fast since you're already hypovolemic)
• Goal is urine sodium:potassium ratio is 1 or higher
• For furosemide: weight and BUN/creatine ratio (using baseline ratio, not 20:1 ratio since they are not producing urea very well d/t malnourishment)

Adding the albumin will increase the oncotic pressure and draw fluid into the vasculature

PMN ≥ 250/mm³

AG, FQ, Metronidazole, or Pip-tazo for anaerobic and gram negative coverage

Norfloxacin or Bactrim

avoid overdiuresis

• Islets produce insulin
• Acinar cells produce enzymes
• Bicarbonate protect intestine from low pH

• food in the duodenum stimulates CCK (cholecystokinin)
• CCK stimulates enzyme production
• Trypsinogen is cleaved by enterokinase to trypsin
• Trypsin activates pro-enzymes

• food in the duodenum stimulates secretin
• Secretin stimulates production of bicarb and water secretion into the duodenum

• Gall stones
• Alcohol
• Hypertriglyceridemia
• Diuretics
• Sulfonamides
• Valproate

• Elevated amylase and lipase
• Lipase more indicative

• At admission:
• Age > 55
• WBC > 16,000/mm³
• BG > 200mg/dL
• AST > 250 IU/L
• ALT > 350 IU/L
• At 48 hours:
• Ca < 8 mg/dL (very bad sign)
• Hematocrit drop > 10%
• Oxygen < 60mmHg
• BUN increased by ≥ 5mg/dL after IV hydration
• Base deficit > 4 mEq/L
• Sequestration of fluids > 6L

• Fluid resuscitation (#1 priority)
• Pain control (#2 priority)(Hydromorphone preferred)
• Parenteral nutrition or enteral feedings distal to the jejunum (to avoid further enzyme production)

• Octreotide (decreases secretions, but not very efficacious)
• Antibiotic prophylaxis (ceftazidime, metronidazole, amikacin, or imipenem-cilastatin)

• Wt loss
• Abdominal pain after eating
• Malabsorption
• Diarrhea
• Diabetes
• amylase and lipase levels are usually normal because there's not enough production to get it into the blood

• Enteric coated pancreatic enzymes
• H2RA or PPI to keep pH around 5 and protect the enzymes