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Flashcards in 117b Complications of cirrhosis Deck (22):
1

complications of cirrhosis

ascites and hepatic hydrothorax (through diaphragm via holes)
HPS and HRS
Varices --> bleeding
encephalopathy (ammonia)
HCC

2

where does cirrhosis damage occur in the liver that leads to portal HTN? What else contributes to ascites?

scarring in sinusoids --> portal HTN

arterial splanchnic vasodilation leads to blood pooling

3

stellate cells - location and role in cirrhosis

space of disse

lay down collagen from hepatic injury --> fibrosis --> cirrhosis

4

ascites development - pathogenesis and timeline of fluid build up

portal HTN -->
systemic + splanchnic vasodilation via NO -->
lowers renal perfusion --> increased RAAS, SNS, ADH --> retain salt and water --> fluid oozes from abdominal organs

fluid build up quickly

5

ascites and hepatic hydrothorax - what labs confirm that its from portal HTN?

-high SAAG (serum ascites albumin gradient) = serum albumin - ascites albumin
-lower protein (<2.5)

6

Ascites and Hepatic Hydrothorax - treatment + what should never be used?

1) salt < 2 g/day (usually not fluid restriction unless hyponatremic in late stages)
2) diuretics - lasix (furosemide) and aldactone (spironolactone)
3) paracentesis as needed
4) prophylaxis against SBP (spont bact peritonitis) in some patients
5) Use TIPS.

Never put in a chest tube OR drainage catheter in abdomen -- high risk of infection without benefit

7

when should prophylaxis for SBP be considered?

GI bleeds
Hostpialized patient (protein <1.5)

8

TIPS and what it does

Transjugular intrahepatic portosystemic shunt
bypasses liver sinusoids - reduces ascites by reducing portal HTN

9

hepatopulmonary syndrome - what happens in the lungs? what does this lead to?

intrapulmonary vascular dilations (IPVD) from NO at base of lung --> hypoxia due to ventilation/perfusion mismatch

10

HPS patient symptoms/findings and treatment

1) spider angiomata
2) orthodeoxia playpnea - sit up and get short of breath and deoxygenated
treatment - supplemental O2 and transplant (curative)

11

hepatorenal syndrome - pathogenesis and outcomes

cirrhosis --> portal HTN --> splanchnic and systemic vasodilation --> low effective circulating volume --> heart pumps harder (high output heart failure) + increased Na/water retention + kidney vasoconstriction

reversible
high risk of death

12

HRS treatment

1) hold diuretics
2) volume replacement with albumin -> increases kidney perfusion
3) if 48 hrs w/out improvement -> use cocktail
albumin
octreotide (reduces splanchnic vasodilation)
midodrine (a-agonist - systemic vasoconstrictor)

13

portal HTN - varices locations

esophageal
caput medusae
hemorrhoids
other locations

14

varices treatment goal and specific agents/procedures

goal is to reduce risk of bleeding

1) nonselective B-blockers (propran, nad, carved _olol) "PROPer CARVED NADs"
highest dose tolerable
B1+B2 (2=unopposed alpha reduces inflow via vasoconstriction, 1=slows heart and CO)
2) band ligation

15

variceal bleeding treatment

antibiotics
octreotide - reduces portal HTN via splan vasodilat
bands
TIPS for recurrent

16

hepatic encephalophaty - what substances cause it and why does it occur?

ammonia + toxins from bacteria in intestines

bypass liver via shunts (TIPS increases) AND bad liver function

17

what type of patient gets hepatic encepahlopathy? what occurs in the brain? treatment?

acute liver failure; edema and herniation; use dialysis

brain adapts to chronic liver cirrhosis

18

hepatic encephalopahty presentation

1) confusion
2) somnolence
3) asterixis - flapping when hand is up with wrist flexed back

19

treatment of hepatic encephalopathy

1) reduce gut bacteria --> rifaximin
2) trap ammonia --> lactulose (ionizes), zinc
3) never protein restrict

20

what type of blood supply does HCC have? does it occur with or without cirrhosis ?

arterial - can be diagnostic w/out biopsy AND used to treat

always occurs with cirrhosis

21

how often should cirrhosis get imaged for HCC?

every 6 months with advanced fibrosis and cirrhosis

22

HRS patient findings

ascites
hypotension
low urine output
hyponatremia