Cirrhosis Chalk Talk

 Decompensated Cirrhosis:

- etiology:
- HE: prior hospitalizations w/ HE: y/n
- rifaximin, lactulose for goal 3-4 BM
- EV: last EGD:
- Ascites/SBP: 
- HCC: Liver US
- PVT: Liver US
- transplant: defer workup to hepatology

Summary

- Background: Cirrhosis distortion and formation of regenerative nodules

- Complications of Cirrhosis: VIBES: volume (ascites, HRS), Infection (SBP), Bleeding (Variceal bleeding), Encephalopathy, screening

- Goals of Management:

- Prognosis:

Complications: 

General Management

1. Discontinue alcohol – baclofen (reduce alcohol consumption & craving)

2. Renal perfusion (NSAIDs, ACEs, ARBs) lower arterial BP associated w/ lower survival (propranolol, ACEis, bbs). “cirrhosis cures htn” MAP < 82 2 yr survival 20%, MAP > 82 2 yr 70%

3. Txt underlying liver disease

4. Sodium restriction: fluid restriction Na < 120 mEq/L

5. Diuretics: Spiro/Furosemide 100:40, titrate > 3 to 50 days. Stage 1 100:40 stage 2 200:80; stage 3 300:120 stage 4 max: 400: 160. Paracentesis 6 to 8 g/L removed.

Liver transplant + shunt. Therapeutic paracentesis & TIPS: transjugular intrahepatic portosystemic shunt

Chronic albumin, SGLT2

Cirrhosis etiology coggle it

Umbilical hernias: repair umbilical hernias, elastic/Velcro abdominal binders reduce pain

Hyponatremia, variceal bleeding (beta blocker, ligation), carcinoma (hepatocellular, ultrasonography), HE grade 1, 2, 3, 4 lactulose, rifaximin. Cirrhosis associated immune deficiency: UTIs, pneumonia, SBP, cryptococcal meningitis

Prognosis

Compensated Cirrhosis: compensated cirrhosis > 12 yrs.

Decompensated cirrhosis: VIBES: < 6 mo. Decompensated cirrhosis Child-Pugh >12 MELD > 21

Predictive Models

- Child Pugh:

- MELD score: 

HEPATORENAL SYNDROME

rise in cardiac output and fall in systemic vascular resistance

holding diuretics and giving albumin worsens hepatorenal syndrome, 1 gram per kilogram per day x48 hours

albumin and holding diuretics with response more likely prerenal

Treatment

Antihypertensives discontinued in all patients with hepatorenal syndrome

ICU: 

- norepinephrine IV continuous gtt (0.5 to 3mg/hr) goal raising MAP by 10mmHg albumin given as intravenous bolus (1 gram/kilogram per day [100gram meximum])

non-ICU

- terlipressin therapy (analogue of vasopressin)

- combination of midodrine, octreotide, and albumin

fail therapy - TIPS

MELD score - liver translant 

Portal hypertension