Academic Day Seminar – Dec 9

✔ Liver Disease

Nina and Alex did a fantastic job covering a very complicated and large topic! These are my notes along with notes from a therapeutic discussion with my Medicine preceptor: liver-disease-ads-notes

How I will apply this:

  • When comparing beta-blockers for esophageal varices, consider pharmacokinetics
    • Non-selective BBs: block adrenergic dilatory tone in mesenteric arterioles, resulting in unopposed alpha adrenergic mediated vasoconstriction and a decreased portal inflow
    • Nadolol 20-40mg daily, adjusted to maximum tolerated doses
      • Duration: 17 to 24 hrs
        • May be harder to titrate esp if patient has hypotension and may have to start with very low doses
        • Keep in mind that cirrhotic patients are typically normotensive at baseline
    • Propranolol 20mg BID, adjusted to maximum tolerated doses
      • Duration: 6-12 hrs (IR), 24-72 hrs (ER)
  • If patients had shunt surgery or TIPS procedure to control variceal bleed, reassess any seconday prophylactic medications they may be on as generally not required in this patient population
    • If recurrent variceal bleeds despite non-selective BB + EVL, consider appropriateness of TIPS
  • Ensure that cirrhotic patients with a variceal or non-variceal GI bleed are empirically treated with antibiotics as it improve survival
  • For SBP, 5 days ~ 10 days of antibiotic treatment – reassess duration of therapies > 5 days (may require longer if clinically unstable)
    • Secondary ascitic infections require source control (e.g. surgery), in addition to antibiotics
  • When assessing for the potential for hepatic encephalopathy, assess for the presence of any precipiating factors (e.g. hypovolemia, sedatives, narcotic analgesics, azotemia or kidney failure) and control them!
    • ~90% of patients can be treated with just correction of the precipitating factor!
    • Treat only overt hepatic encephalopathy as mortality benefit only proven for OHE but when excluded high bias trials, mortality became NSS (if minimal HE – may discuss treatment with patients if QOL and cognition is impacted)
  • Do not automatically treat high ammonia levels (does not correlate with staging or level or severity of symptoms of HE) – if asymptomatic, patient does not require treatment …patients may also have symptoms of HE with normal ammonia levels