以下先週のNEJM review articleのまとめです。
個人的には
・BBの中止のタイミング
・鎮静にアラックスP®
・アセトアミノフェンの使用も可能であるが、hepatologistは2g/d程度にしている
などが勉強になりました。
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N Engl J Med 2016;375:767-77.
irreversible fibrosis of liver
8th leading cause of death in US
13th leading cause of death in world
cause
HBV, HCV, EtOH, NASH
10 yrs probability of compensated cirrhosis
47% ascites
28% hepatic encephalopathy
25% GIB
5% annual HCC incidence
Food management
1-1.5g/kg daily protein intake is recommended even in Hx of hepatic encephalopathy
late evening meals
2000mg limit in daily NaCl → treatment for ascites
Medication
hypertension may be improved during cirrhosis advanced
・BB is indicated for moderate-large esophageal varices
stop BB when sBP < 90mmHg, s-Na < 120 mmol/l, AKI, refractory ascites, hypotension, hepatorenal syndrome, SBP, sepsis, severe alcoholic hepatitis develops (end-stage cirrhosis remain controversial)
・midodrine may improve hemodynamic variables
combination midodrine + octreotide for type 1 hepatorenal syndrome
・pain-killer
acetaminophen daily max dose 4g, but many hematologists limits 2g daily
・PPI no needed without any documented indication
・sedation lorazepam(ワイパックス®、ジェネリック) and oxazepam（日本販売中止） are preferred
hydroxyzine 25mg/vds（アタラックス®） may be alternative
・statin safe, only 22 cases of drug-induced liver injury
・tolvaptan, vaptan not recommended
・baclofen for suppression of alcohol cravings
Surgery
MELD score to predict 30 days post-operative mortality
MELD > 14 associated death with abdominal surgery than Child-Pugh C
MELD +1 +1% mortality among MELD < 20
MELD +1 +2% mortality among MELD > 20
Paracentesis
diuretic-sensitive ascites → 5L removal is enough to reduce intraabdominal pressure
Endoscopic band ligation
preferred for medium-large esophageal varices
follow-up
abdominal US or CT every 6mon
serum AFP follow may be improve effectiveness of surveillance for HCC
ABx prophylaxis (ST or CPFX) for Hx of SBP or hospitalization with ascites protein < 1.5g/dl
Px
compensated cirrhosis 4.7 times risk of death compare to general population
average life expectancy of compensated cirrhosis 10-13 yrs
average life expectancy of decompensated cirrhosis 2 yrs
delayed paracentesis associated with 2.7 times risk of death
65% death in 3 yrs for stopping EtOH with alcoholic cirrhosis
100% death in 3 yrs for non-stopping EtOH with alcoholic cirrhosis
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