Liver Disease Topic Discussion PDF

Cirrhosis & its complications
Condition where the liver is scarred and becomes permanently damaged, therefore, it is unable to function
properly
Functions of the Liver

- Detoxification, nutrient processing, cholesterol production, protein synthesis, storage, blood sugar
regulation, bile production, regulates blood composition, etc …
Common Causes & Signs and Symptoms

- Alcoholism, viral diseases (hepatitis), some medications, immunologic, non-alcoholic fatty liver disease
(NASH)
- Vaccinations and antiviral treatment have helped the number decrease however increased injection
drug use and alcohol use are allowing those number to start to increase again
- Signs & Symptoms: jaundice, abdominal pain, confusion, swelling, nausea, loss of appetite, etc …
Diagnosis
- Based on medical history, a physical exam, and lab results:
AST & ALT Increased value in the blood indicates liver damage
Alkaline phosphate Increased value indicates decreased liver function
Bilirubin Increased value indicates decreased liver function
Albumin Decreased value indicates decreased liver function
INR Increased value indicates decreased liver function
- Child-Turcottee-Pugh  used to predict mortality
o Child-Pugh A: 5-6 points Points are based on encephalopathy, ascites,
o Child-Pugh B: 7-9 points bilirubin, albumin, prothrombin time (can also use
o Child-Pugh C: 10-15 points INR)
- Categories
o Compensated: Liver is heavily scarred but still functions
o Decompensated: Liver is extensively scared and is unable to carry out normal functions
Ascites
- Activation of the renin-angiotensin-aldosterone system leads to sodium and water retention
o Should avoid ACEI/ARBs and nephrotoxins
o Important to avoid NSAIDs and TZDs (due to increased fluid retention)
- Treatments
o Paracentesis: removal of the fluid in the peritoneal space
o Albumin: indicated in paracentesis ≥ 5L removed (helps maintain the intravascular volume)
 For each liter removed  give 6 - 8g of albumin
o Diuretics: helps excrete water and sodium
Furosemide Spironolactone
- 40mg PO daily - 100mg PO daily
- ADR: AKI, electrolyte - ADR: gynecomastia, dehydration,
abnormalities ↑K, hypotension
- Monitor: SCr, wt, Na, K, - Monitor: SCr, wt, Na, K
 Midodrine: Can be used for refractory ascites [7.5mg PO TID]
Hepatorenal Syndrome
- Marked vasoconstriction of the renal arteries due to systemic vasodilation
- Management
Discontinue diuretics Give albumin 25% 1g/kg on ICU: Norepinephrine 0.5-3mg/hr
or treat the cause of day 1 then 40-50g/day for up Non-ICU: Midodrine 7.5-15mg and
the AKI to 14 days octreotide 100-200mg TID
Continue therapy until SCr returns to
baseline (max 14 days)
Spontaneous Bacterial Peritonitis (SBP)

- Bacterial infection of the ascitic fluid
- Common organisms include E coli., Klebsiella pneumoniae, Streptococcus pneumoniae, enterococcus,
and Proteus
- Diagnosed by PMNs ≥ 250 in paracentesis fluid and hemodynamically instability
Primary Prophylaxis Ascitic fluid protein < 1.5 + one of the following: SCr > 1.2, Na < 130, liver failure
- Ciprofloxacin 500mg/day
- Levofloxacin
- Bactrim
Acute Management Antibiotics should be initiated after blood cultures are drawn
- 3rd generation IV cephalosporins (ceftriaxone and cefotaxime)
- Can switch to PO once improving (cefdinir and cefpodoxime)
- MDRO or recent exposure to antibiotics: broad spectrum antibiotics
- Could use fluoroquinolones if not used for primary prophylaxis
- Treat for at least 5 days
Albumin 25%: 1.5g/kg on day 1, then 1g/kg on day 3
- Only given if SCr > 1, BUN >30, total bilirubin >5
Secondary Prophylaxis After 1 episode of SBP
- Ciprofloxacin 500mg daily
- Levofloxacin 750mg daily
- Bactrim DS PO BID
Varices
- Abnormal, enlarged veins normally caused when blood flow to the liver is blocked
- Must have evidence of varices before initiating therapy
- Primary prophylaxis
Propranolol 20mg PO BID MOA: reduce portal pressure
Nadolol 40mg PO daily ADR: bradycardia, hypotension, fatigue,
Carvedilol 3.125mg PO BID lightheadedness
- When there is an active bleed
o Discontinue all beta blockers
o Initiate octreotide 50mcg IV bolus followed by 50mcg/hr infusion for 2-5 days
 MOA: reduction in portal pressure
o Give antibiotics to prevent SBP for a duration of 7 days
 Ciprofloxacin 500mg daily
 Ceftriaxone 1g daily
 Unasyn 1.5g Q6H
- Secondary prophylaxis
o Propranolol 20mg PO BID
o Nadolol 40mg PO daily
Hepatic Encephalopathy
- Decreased removal of toxins from the blood due to liver damage causing symptoms such as confusion,
slurred speech, shakiness, and forgetfulness
- No treatment for primary prophylaxis
- Acute Episode
o Assess for predisposing factors and nutrition
o Lactulose:
Acute Maintenance
30-45mL PO hourly until bowel movement 30mL PO 3-4x/day titrated to 2-3 soft
then Q8H titrated to 2-3 soft bowel bowel movements/day
movements/day
 Does have the risk for overuse/misuse
o Rifaximin 550mg PO BID
 Used to decrease recurrence and for maintenance
o Second line antibiotics
 Metronidazole 500mg PO/IV TID
 Neomycin 1-2g PO Q6H
- Secondary prophylaxis / Maintenance
o Lactulose ± Rifaximin
Resources
- Lee Y, Tee H, Mahadeva S. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding.
World J Gastroenterol. 2014;20(7):1790-1796. Doi: 10.3748/wjg.v20.i7.1790.
- Tsoris A, Marlar C. Use of the Child Pugh Score in Liver Disease. StatPearls Publishing. 2022.
https://www.ncbi.nlm.nih.gov/books/NBK542308/
- Biggins S, Angeli P, Garcia-Tsao G, Ginès P, Ling S, Nadim M, Wong F and Kim W. Diagnosis, Evaluation,
and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021
Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74:
1014-1048. https://doi.org/10.1002/hep.31884
- Moon A, Singal A, Tapper E. Contemporary Epidemiology of Chronic Liver Disease and Cirrhosis. Clinical
Gastroenterology and Hepatology. 2020;18(12):2650-2666. https://doi.org/10.1016/j.cgh.2019.07.060.
- Leise M, Poterucha J, Kamath P, Kim W. Management of Hepatic Encephalopathy in the Hospital. Mayo
Clinic Proceedings. 2014;89(2): 241-253. https://doi.org/10.1016/j.mayocp.2013.11.009.

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Cirrhosis & its complications

Functions of the Liver

Common Causes & Signs and Symptoms

Spontaneous Bacterial Peritonitis (SBP)

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