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Medicine - Cirrhosis + Portal HTN (ii) (Ascites (stepwise management…
Medicine - Cirrhosis + Portal HTN (ii)
Ascites
most common complication of cirrhosis
results from portal HTN + consequent vasodilation
can be responsive/uncomplicated, or refractory/resistant
complications
hyponatraemia
SBP
HRS (2 types)
most common cause = cirrhosis
other causes
peritoneal malignancy
HF
peritoneal TB
pancreatitis
nephrogenic ascites
Budd-chiari syndrome (rare hep vein occlusion)
pathogenesis
hep outflow obstruction -> increased sinusoidal pressure
splanchnic vasodilation -> decreased blood vol -> RAAS activation -> Na + water retention
fluid analysis
routine
albumin/protein (confirms cirrhosis)
WCC (esp PMN) + gram stain + cultures (check for SBP)
optional
glucose
LDH
amylase
RCC
TB smear + culture
cytology (rule out malignancy)
TGs
stepwise management
Tx underlying liver disease
Na diet restriction: 90 mmol/day
Spironolactone (K-sparing diuretic, aldosterone antagonist, SE = gynaecomastia)
add furosemide (loop diuretic, SE = low K)
complications of diuretics in ascites
HE
renal failure
hyponatraemia
hypo/hyper kalaemia
severe muscle cramps (give quinine or Mg2+)
Large vol paracentesis (LVP), with albumin infusion prior (stops rebound pul oedema) - can start @ this step for massive ascites
TIPSS
transplant
SBP
commonest infection in cirrhotic patients
Dx = paracentesis
if signs/symptoms occur
unexplained encephalopathy or renal failure
any hosp admission with advanced liver disease (<24hrs after admission)
PMN count > 250/mm3
after Dx do transplant assessment
determine aetiology via ascitic fluid analysis
WBC differential
gram stain (>1 organism suggests secondary to something, e.g. perforation)
SAAG (serum ascites albumin gradient) - >1.1 g/dL suggests portal HTN
cultures (aerobic + anaerobic)
Tx
recommended initial antibiotics
IV cefotaxime
IV co-amox
avoid aminoglycosides
oral ofloxacin (if uncomplicated)
min duration = 5 days
IV high dose albumin on days 1 + 3
re-evaluate if PMN count hasn't decreased by @ least 25% after 2 days on tx
once daily antibiotic prophylaxis (e.g. ciprofloxacin) must be prescribed long-term post SBP)
HRS
RF in patients with cirrhosis, advanced liver failure + severe portal HTN/ascites
marked art vasodilation in extra-renal circulation - extreme underselling - reduced renal blood flow + GFR, renal vasoconstriction
functional RF (kidneys are normal)
bad prognosis - patients lives days/wks, occasionally months
Median survival in cirrhosis
compensated: 12 yrs
decompensated: 1.6 yrs
hepatopul syndrome: 10 mo
SBP: 9 mo
HRS
type 1: 2 wks
type 2: 6 mo (a/w tx-resistant ascites)
Considering transplant
Child-Pugh score =/> B7
incorporates bili, INR, albumin, HE, ascites
MELD =/> 15
incorporates bili, creatinine, INR
model of end stage liver disease
Hepatitis
acute
ALT in 1000s
viral (A-E)
AIH
drugs (paracetamol)
vasc (ischaemia/infarct)
Wilson's if younger (copper overload)
chronic
much commoner
ddx broader
tx less urgent
how to dx
good hx (incl social)
exam
check for viral, metabolic + immune causes
do US
followup
bx in minority