The discussant divided the complications into those related to portal hypertension and those not related to portal hypertension. This is a useful framework.
Remember, if you can stop the process that is damaging the liver (ETOH, HBV, HCV) you may be able to make a big difference in patient outcomes.
Portal HTN related:
Varices - Esophogeal, Gastric
- Avoidance (if possible) of NSAIDs
- Surveilance OGD q2 years if no varices, q1 year if low grade varices, more frequently if high grade varices or bleeding
- Endoscopic therapy (banding): For those with high grade varices or those who have bled (may not be superior to pharmacotherapy).
- Pharmacotherapy: non-selective beta-blockers +/- isosorbide mononitrate for patients with known varices and those who have bled
- Combination of both endoscopic therapy and pharmacotherapy may be the best for primary and secondary prophylaxis
- Fluid and Salt Restriction
- Diuretics: spironolactone and furosemide (oral) in dose ratio of 100:40 titrated to effect. Goal is to increase 24h sodium excretion above intake
- Therapeutic Paracentesis
- TIPS
Splenomegaly and hypersplenism
Hepatorenal or Hepatopulmonary syndromes
Non-Portal Hypertension Related:
Encephalopathy
- Avoidance of precipitating medications (benzos, narcotics) and foods (e.g. high protein load)
- Recognizing precipitants -- GI bleeding, infection, renal failure, hypokalemia
- Protein restriction
- Lactulose -- Often used with little evidence
- Antibiotics -- RIFAMIXIN
Hepatoma:
- Risk Factors:
HBV, HCV, FHx, Toxin Exposure, (?smoking) - Screening: Ultrasound +/- AFP on an annual basis for those with high risk features
- Early treatment
We also talked about the Child-Pugh and MELD scores as prognostic aids and tools for selecting patients for transplantation referral.
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