Snapshot A 65-year-old man is brought to the emergency room for abdominal pain. He has a history of alcohol abuse. He reports that he has felt fatigued, itchy, and “out of it” for the past several weeks. His wife also noticed that his skin looks more orange. On exam, his abdomen is distended with a positive fluid wave. Dermatologic exam reveals jaundice, palmar erythema and spider angiomata. A hepatic ultrasound shows nodularity and fibrosis of the liver. Introduction Overview cirrhosis is a liver disease characterized by hepatic fibrosis, regenerative nodules, and dysfunction Epidemiology incidence very common cause of death risk factors alcoholic liver disease (most common) nonalcoholic steatohepatitis chronic viral hepatitis autoimmune hepatitis hepatocellular carcinoma primarily biliary cirrhosis α1-antitrypsin deficiency Wilson disease hemochromatosis Pathogenesis mechanism chronic liver damage results in nodules surrounded by fibrosis abnormal wound healing with continued connective tissue deposition, resulting in fibrosis results in damage to hepatic vasculature fibrosis causes shunting of portal and arterial blood impairs metabolism of estrogen Prognosis Model for End-Stage Liver Disease (MELD) score predicts 3-month mortality in patients with cirrhosis creatinine bilirubin INR Presentation Symptoms common symptoms fatigue weakness weight loss loss of appetite pruritus upper gastrointestinal bleeding Physical exam inspection mental status changes signs of liver disease jaundice gynecomastia ascites palmar erythema spider angiomata hepatosplenomegaly bleeding Imaging Liver ultrasound indications all patients findings fibrosis nodularity increased echogenicity atrophy or hypertrophy of liver lobes Transient elastography indications measures liver stiffness all patients findings hepatic fibrosis and increased stiffness Studies Serum labs multiple severity scores exist for cirrhosis but often include ↑ liver enzymes AST:ALT > 2 suggests alcoholic cirrhosis ↑ prothrombin time treat with fresh frozen plasma or factor replacement ↑ direct bilirubin ↓ platelets creatinine determining etiology hepatitis B and C serology alpha-1 antitrypsin levels antinuclear antibody anti-smooth muscle titers antimitochondrial antibody ferritin transferrin saturation levels 24-hour copper level in the urine ceruloplasmin hemochromatosis genetic testing Invasive studies liver biopsy indications patients who cannot undergo transient elastography clinical presentation is not consistent with a diagnosis Differential Acute viral hepatitis key distinguishing factor acute onset of symptoms with viral prodrome, nausea, vomiting, and abdominal pain lacks findings of chronic liver disease Treatment Management approach treat underlying cause if possible Lifestyle diet with restricted sodium indications all patients with ascites alcohol and smoking cessation Medical antibiotic prophylaxis for spontaneous bacterial peritonitis indications cirrhosis and gastrointestinal bleeding or ascites vaccinations indications all patients modalities hepatitis A hepatitis B 23-valent pneumococcal vaccine Surgical liver transplantation indications refractory liver cirrhosis major complications ascites variceal bleeding hepatic encephalopathy Complications Hepatocellular carcinoma screening liver ultrasound and alpha-fetoprotein every 6 months Spontaneous bacterial peritonitis Esophageal or gastric varices screening esophagogastroduodenoscopy (EGD) treatment banding TIPS procedure Hepatic hydrothroax ascites/fluid accumulation that enters the pleural space and impairs pulmonary mechanics treatment salt restriction (first-line) diuretics (loop or thiazide)
QUESTIONS 1 of 4 1 2 3 4 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.GI.4691) A 49-year-old woman with a history of hepatitis C cirrhosis complicated by esophageal varices, ascites, and hepatic encephalopathy presents with 1 week of increasing abdominal discomfort. Currently, she takes lactulose, rifaximin, furosemide, and spironolactone. On physical examination, she has mild asterixis, generalized jaundice, and a distended abdomen with positive fluid wave. Diagnostic paracentesis yields a WBC count of 1196/uL with 85% neutrophils. Which of the following is the most appropriate treatment? Review Topic QID: 107598 Type & Select Correct Answer 1 Large volume paracentesis with albumin 0% (0/0) 2 Increased furosemide and spironolactone 0% (0/0) 3 Transjugular intrahepatic portosystemic shunt placement 0% (0/0) 4 Cefotaxime 0% (0/0) 5 Metronidazole 0% (0/0) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 4