8. Variceal hemorrhage : Primary
prophylaxis
• Endoscopy of all patient with cirrhosis if normal follow up q 2-3
years
• Non selective Beta blocker (propranolol, carvedilol)
• Esophageal variceal band ligation
• Transjugular intrahepatic portosystemic shunt
9. Drug : variceal bleeding
• Splanchnic vasoconstriction
• Somatostatin 250 mcg iv bolus, then drip 250 mcg/hr
• Octreotide 50 mcg iv bolus, then drip 50 mcg/hr
• Terlipressin0.5-2 mg iv q 4 hr in 48 hr then 1 mg iv in q 4 hr (Caution in
CAD,PVD)
• Antibiotic prophylaxis
• Norfloxacin400 mg bid x 7 days (ciprofloxacin)
• IV ceftriaxone1 g/dayx 7 days ( in childB-C, NPO)
3-5 days
21. Albumin therapy in SBP !?
This graphicshows that the additionof albuminto cefotaximeclearlyprevented
renal impairmentand improved mortalitywhen comparedwith cefotaximealone.
p values: renal impairmentp=0.002, in-hospitalmortalityp=0.01, 3 month
mortalityp=0.03
Sort P, Navasa M, Arroyo V, et al. N Engl J Med. 1999;341:403-9
23. ** SBP prophylaxis ;Why ?
•Cirrhotic patient with ascites or previous SBP
have high recurrent rate. (70%)
•High mortality rate of SBP
(9 mo of mean survival time)
•Selective intestinal decontamination
•Increased risk of drug resistant ?
24. ** SBP prophylaxis ;When ?
•Primary prophylaxis
•Cirrhotic ascites with GI hemorrhage
•Cirrhotic ascites with LOW protein in ascites
(<1.5g/dl) + Cr > 1.2 mg/dl or BUN > 25 mg/dl
or serum Na <130 mEQ/l
•Cirrhosis with Child Pugh score > 9 (Child C) +
serum TB > 3 mg/dl
•Secondary prophylaxis
•Hx of previous SBP
AmericanAssociationforthe Study of Liver Diseases(AASLD) 2014
25. ** SBP prophylaxis ; How ?
•Ciprofloxacin or other fluoroquinoloneor
Bactrim
Ciprofloxacindose = 500 mg / day
•NPO ? >>Ceftriaxone 1 g iv OD
•Duration ? >> life long or out of cirrhosis
forGIB case… 7 days
AmericanAssociationforthe Study of Liver Diseases(AASLD) 2014
27. Definition
•A serious complication of chronic liver disease ,
defined as an alteration in mental status and
cognitive function occurring in liver failure.
•Ammonia level
•A.K.A. Portosystemic encephalopathy
•Types : A-B-C
Testing for Asterixis (Flap Test)
To test for asterixis, the arms are extended
and the wrists dorsiflexed.
30. Common precipitating factors
‘BIGSCALP’
B = Blood transfusion
I = Infection
G = GI bleed
S = sedative drug and tranquilizer
C = constipation
A = alkalosis
L = low k
P = high protein diet, Portosystemic shunt
32. Summary points for HE
• Overt hepatic encephalopathy consists of neurological and psychiatric
abnormalities that can be detected by bedside clinical tests, whereas
minimal hepatic encephalopathy can only be distinguished by specific
psychometric tests.
• There are many grading scales available for hepatic encephalopathy,
including the long standing West Haven Criteria, which is the most
commonly used system.
• Diagnosis of overt hepatic encephalopathy requires the exclusion of
alternate causes of altered mental status. Serum ammonia levels
should not be used as a diagnostic tool or as a means of monitoring
response to treatment.
• Treatment of acute overt hepatic encephalopathy should include: (1)
supportive care, (2) identifying and treating any precipitating factors,
(3) reduction of nitrogenous load in the gut, and (4) assessment of need
for long-term therapy and liver transplant evaluation.
33. Summary points for HE
• Lactulose can be used as initial drug therapy for the treatment of acute
hepatic encephalopathy. Rifaximin should be added for those patients
who do not have an adequate response to lactulose. Subsequently, the
addition of oral branched-chain amino acids or intravenous L-ornithine-
L-aspartate can be considered in patients who do not respond to the
combination of lactulose and rifaximin.
• Prevention of recurrent hepatic encephalopathy or treatment of persistent
hepatic encephalopathy includes drug therapy as well as prevention or
avoidance of precipitating factors.
• Protein restriction should be avoided as a general rule, as it can actually
lead to worsening of hepatic encephalopathy. Cirrhotic patients are
advised to consume 1.25 to 1.5 g/kg protein daily.
• Liver transplant evaluation should be considered in appropriate
candidates once a diagnosis of overt hepatic encephalopathy is made.
Liver transplantation is indicated in patients who have liver failure and
recurrent intractable overt hepatic encephalopathy.