Liver Disease

What are the signs/symptoms of liver disease?

What are the signs/symptoms of liver disease?

§  Jaundice

§  Pruritis

§  Fatigue

§  N/V

§  Poor appetite

§  Right upper quadrant pain

§  Scleral icterus

§  Ascites

§  Spider angiomas

What lab values can be indicators of liver disease?

§  ↓ Albumin (3.4-4.7 g/dL)

§  ↑ AST/ALT (6-50 IU/L)

§  ↑ Alkaline Phosphatase (30-120 IU/L)

§  ↑ Bilirubin (0.3-1.9 mg/dL)

§  ↓ Platelets (150-450k/mm³)

§  ↑ PT/INR (11-15sec/0.8-1.2)

Child -Pugh Classification

Score	1	2	3
Bilirubin (mg/dL)	<2	2-3	>3
Albumin (g/dL)	>3.5	2.8-3.5	<2.8
Ascites	None	Mild	Moderate
Encephalopathy	None	Grade 1-2	Grade 3-4
INR	<1.7	1.7-2.2	>2.2
PT (sec)	<4	4-6	>6

What is considered a Grade A child Pugh Classification?

<7

What is considered a grade B Child Pugh score?

-7-9

What is considered a Grade C Child Pugh score?

->10

True/False: The higher the Child Pugh score the greater the mortality risk from cirrhosis

-True

What is the most common complication seen with liver disease?

-Ascities

What is the management strategy for ascities?

-sodium fluid retention

-diuretics

-paracentesis

-albumin ( if the patient has 5 L or more removed than you need to replace fluid with albumin)

-Antibiotics (SBP): if fluid is infectious

What diuretic combination is used for ascites?

-Spironolactone 100 mg + Furosemide 40 mg daily.

What are the common pathogens that cause Spontaneous Bacterial Peritonitis (SPB)?

-E. Coli

-Klebsiella pneumoniae

-Pneumococci

What is the initial treatment for Spontaneous Bacterial Peritonitis?

-3rd generation cephalosporin:

• Cefotaxime 2 g IV q8h

• Ceftriaxone 1-2 g IV q24h

• duration: 5 days

What is the medication for secondary prophylaxis for Spontaneous Bacterial Peritonitis?

-Life long and initiated after completion of treatment.

Bactrim DS 1 tablet po daily

Ciprofloxacin 500 mg po daily (most common)

How do you manage portal hypertension/esophageal varices?

·         Primary prophylaxis

·         Treatment of acute bleeding

·         Secondary prophylaxis

What can be indications of esophageal varices?

·         Small varices + wale signs

·         Decompensated patient + small varices

·         Medium to large varices

What is the pharmacotherapy for portal hypertension/esophageal varices?

-Propranolol ( dosed multiple times a day)

-Nadolol(dosed multiple times a day)

-Carvedilol ( dosed twice a day)

What is the treatment for acute variceal bleed?

·         Octreotide: IV infusion ( 50 mcg/hr) for 2-5 days.

o   Adverse effects: hypertension, hyperglycemia, bradycardia

·         Recommended: duration for 7 days.

o   Ceftriaxone

o   Ciprofloxacin

o   SMX-TMP

·         Secondary Prophylaxis:

o   Propranolol or Nadolol plus Endoscopic Variceal Ligation (EVL)

What is hepatic enecephalopathy?

·         Accumulation of gut-derived nitrogenous substances within the CNS

·         Decreased hepatic function and shunting.

·         Alterations in mental status

·         Ammonia – most common culprit

·         Others: glutamine, BZD receptor agonists, aromatic amino acids, manganese

·         Normal serum ammonia: 18-60 mcg/dL

·         No established correlation between serum ammonia and mental status

What is the drugs used to treat hepatic encephalopathy?

-lactulose

-rifaximin

Medications for Hepatic Encephalopathy:

Drug	Dose	Benefit	Monitoring and Counseling	Comments
Lactulose	25 mL (16.7 g) PO every 1-2h until laxative effect; then every 8-12 hrs	Improved cognitive function Most extensively studied ↓ progression to overt HE	Goal: Titrate to 2-3 bowel movements/ day Assess adherence Abdominal pain Cramping  Distention  Flatulence  Nausea/Vomiting	Mainstay of treatment Cost-effective Improved cognitive function Most extensively studied ↓ progression to overt HE Used for treatment and prophylaxis
Rifaximin	550 mg PO twice daily	In combination with lactulose é efficacy and ê mortality	Poor PO absorption; minimal ADEs	Barrier to Access = Assess insurance-May require PA

What are some other complications of Liver disease?

-Hepatorenal syndrome

-Hepatopulmonary syndrome

-Coagulopathies

What are the monitoring and counseling for ascites treatment?

§  Urine output

§  Weight loss

§  BP and irregular heartbeat

§  Electrolytes

§  Counseling:

·         Take in AM

·         Leg cramps

What are the monitoring and counseling points for portal hypertension/esophageal varices treatment?

§  BP and heart rate

§  SOB

§  Hypoglycemia

§  Co-morbidities

§  Adherence

§  Food intake

§  Past therapy

What are the common types of viral hepatitis?

Category	Hepatitis A	Hepatitis B	Hepatitis C
Transmission route	Fecal-oral route (contamination)	Blood and body fluids (sexual contact or shared needles)	Blood (IV drug use or blood exposure)
Acute infection (<6 months)	Yes	Yes	Yes
Pharmacologic treatment for acute infection	No (supportive care only)	No	Yes
Chronic infection (6+ months)	No	Yes	Yes
Pharmacologic treatment for chronic infection	NA	Yes	Yes
Immunity after infection	Yes	Yes	No

When are vaccines recommended for Hepatitis A and Hepatitis B?

	Hepatitis A	Hepatitis B
All infants	No	Yes
All children	Yes	Yes
International travelers	Yes	Yes
Individuals who inject drugs	Yes	Yes
Individuals with chronic liver disease	Yes	Yes
Healthcare workers	Yes	Yes
Men who have sex with men	Yes	Yes
Pregnant women at risk	Yes	Yes
People living with HIV	Yes	Yes
People experiencing homelessness	Yes	No
People with multiple sexual partners	No	Yes
People who are incarcerated	No	Yes
Vaccines	Havrix®, Vaqta®, Twinrix® (A and B)	Heplisav-B®, Recombivax® Engerix-B®, Twinrix® (A and B)

How do you treat Hepatitis C?

-Harvoni and Epclusa are used to treat chronic Hepatitis C.

True/False: Hepatic encephalopathy is most common presentation of cirrhosis and can be managed with lactulose.

-True

True/False: Ascites is best managed using the diuretic combination spironolactone and hydrochlorothiazide

-False

True/False: No vaccines exist for the prevention of hepatitis C.

-True