Alcoholic liver disease

History and physical

100

How many drinks or shots does a 5th of vodka contain?

16

200

Stigmata of alcoholic cirrhosis wherein the sphincteric muscle surrounding a cutaneous arteriole fails 

Spider angiomata

300

Spironolactone and tricyclic antidepressants can also cause this stigmata/ physical exam finding of alcoholic cirrhosis

Gynecomastia

Esophageal varices

100

What are the treatment options for Secondary Prophylaxis following treatment of an Acute Variceal Bleed?

Endoscopic evaluation Beta Blockers: Start Propranolol 10 mg TID or nadolol 20 mg DAILY if patient has large varices Endoscopy: Endoscopic variceal ligation is an alternative prophylaxis strategy

200

Name the 3 Treatment options for an Acute Variceal Bleed

1. Endoscopy 2. Octreotide 3. Prophylatic ABX to prevent SBP: Ciprofloxacin IV/PO or Norfloxacin PO for 7 days – 1st line Ceftriaxone IV if allergies or in areas with high FQ resistance

300

Name the 3 primary prophylatic indicators of Esophageal Varices

1. Varices size – 5 or more mm 2. Varices appearance – red whale marks – puts patients at risk of bleed 3. Stage of liver disease – CP Class B or C patients – high risk of bleed

Prognosis

100

What is included in Maddrey's discriminant function score?

PT, PT control and bilirubin

Scores above 32 typically suggest poor prognosis and that these patients may be helped by steroid administration.

200

What is included in the MELD score?

Cr, bilirubin, INR, sodium, dialysis at least twice in the last week

• Consider referral to hepatologist or liver transplant center for patients with MELD Score ≥10.
• MELD Score should be periodically re-assessed, as it changes with changing lab values.
• All cirrhosis patients should be periodically screened for hepatocellular carcinoma with serum alpha-fetoprotein (AFP) and by appropriate imaging to see if they can earn “standard MELD exceptions”.

300

Name one standard MELD exception

The following conditions are automatically assigned a MELD Score of 22 (28 in case of hyperoxaluria), with a 10% increase in score every 3 months from diagnosis. 

• Hepatocellular carcinoma (HCC) with one lesion between 2 - 5 cm or two to three lesions <3 cm (Milan criteria), provided no vascular invasion or extrahepatic disease.
• Hepatopulmonary syndrome with PaO2 <60 mmHg on room air.
• Portopulmonary hypertension, with mean pulmonary artery pressure (mPAP) >25 mmHg at rest but maintained <35 mmHg with treatment.
• Hepatic artery thrombosis 7–14 days post-liver transplantation.
• Familial amyloid polyneuropathy, as diagnosed by identification of the transthyretin (TTR) gene mutation by DNA analysis or mass spectrometry in a biopsy sample and confirmation of amyloid deposition in an involved organ.
• Primary hyperoxaluria with evidence of alanine glyoxylate aminotransferase deficiency (these patients requires combined liver-kidney transplantation).
• Cystic fibrosis with FEV1 (forced expiratory volume in 1 second) <40%.
• Hilar cholangiocarcinoma.

Labs

100

In what direction to you expect the follow labs to be abnormal 

MCV, WBCs, platelets, ESR

MCV increased

WBC decreased

platelets decreased 

ESR increased

200

True or false: degree of elevation of LFTs correlates to disease severity

False

300

What are potential reasons for macrocytosis in alcoholic cirrhosis?

poor nutritional status, cobalamin or folate deficiency, toxicity of alcohol, and/or increased lipid deposition on red cell membranes. 

Ascites

100

Indication for paracentesis

Indicated if tense ascites (4-6L) before diuretic therapy is initiated or in ascites refractory to diuretic therapy

200

What is the pathogensis of ascites?

Increased hydrostatic pressure in the portal venous system and decreased plasma oncotic pressure Activation of RAS due to transient decrease in arterial blood supply --> increased aldosterone -->Na+ and water retention Excess fluid leaks into peritoneal cavity from the congested portal system

300

hat 2 diuretic drugs are used for treatment of Ascites? Indicate starting and max doses and reason for their combination.

Start spironolactone 100 mg and furosemide 40 mg PO DAILY Rationale for combination: Spironolacton: Aldosterone antagonist Furosemide: to increase mobilization of fluid and counteract possible hyperkalemia with spironolactone alone Titrate the doses every few days but keep the ratio the same Max dose is spironolactone 400 mg per day and furosemide 160 mg per day