Flashcards in 14. Cirrhosis Deck (41):
What will be present on exam in a patient with cirrhosis?
What lab findings will there be with cirrhosis?
Elevated transaminases, bilirubin, ALP, PT/INR
Where is cachexia from cirrhosis especially prominent?
What are spider angioma?
Dilated arterioles in the distribution of the SVC (chest up)
Blanches from the center out with pressure
What causes palmar erythemia with cirrhosis?
Increased estrogen levels leads to increased blood flow in the periphery
Dupuytren's contractures are more common in patients with ___ cirrhosis
What is caput medussae?
Visible abdominal wall collateral veins due to recanalization of the umbilical vein
What cell is causing the fibrosis in hepatic fibrosis?
What criteria does the Child-Pugh Scoring Criteria take into account?
What are the three classes of Child-Pugh
A: 5-6 70-75% 5yr survival
B: 7-9 40-45%
C: >9 10-15%
**transplant survival is around 70%, so don't transplant person with A class
What scoring system is used to rank transplant patients?
MELD model: based on the INR, bilirubin, creatinine, dialysis
What is the normal pressure difference between the portal vein and hepatic vein?
What causes pre-hepatic portal HTN?
Portal vein thrombosis
What is the key cause of intra-hepatic portal HTN?
What are three key causes of post hepatic portal HTN?
1. Hepatic vein thrombosis (Budd-Chiari Syndrome)
2. Right heart failure
3. Valvular heart disease
What are the 6 key complications of cirrhosis?
1. Variceal bleeding
3. Spontaneous bacterial peritonitis (SBP)
4. Hepatorenal syndrome
5. Hepatopulmonary syndrome
6. Hepatic encephalopathy
What is the risk associated with varices
Thin walled--rupture, hard to stop bleeding due to low levels of coagulation factors and sequestration of platelets in the spleen
What drugs are used for varices (non active)?
Beta blockers: decrease the risk of first bleeding, rebleeding, and increased survival
What are the two ways by which beta blockers treat varices?
Decrease CO by blocking beta1
Produce sphanchnic vasoconstriction by blocking beta2
What tx is used for active variceal hemorrhage?
Octreotide: somatostatin analog, decreases intestinal blood flow
Band ligation may also be used
What is the pathophysiology of ascites with cirrhosis?
Increased resistance to portal flow
Splanchnic arterial vasodilation
Decreased effective circulating volume
Activation of vasoconstrictor/antinatriuretic factors (renin, angiotensin, aldo, vasopressin)
Sodium and water retention
Plasma volume expansion
Is water retention or sodium retention greater with cirrhosis?
Water retention from increased vasopressin--leads to hyponatremia
What are the components of management of ascities?
1. 2000 mg sodium restricted diet
2. Diuretics- spironolactone (aldo inhibitor) and furosemide
What are the two key sx of patients with SBP (spontaneous bacterial peritonitis)
Abdominal pain 80%
What are pathogens commonly involved in spontaneous bacterial peritonitis?
G- bacilli 8%
**60-70% gram - because that is what is found in the GI tract
What is hepatorenal syndrome?
Progressive renal failure associated with advanced cirrhosis and ascities
What type of renal failure presents with urine sodium over 20 and cell debris in the urine?
Acute tubular necrosis
What happens to the urine sodium in hepatorenal syndrome?
<10; kidneys sense that they are not being perfused because there is so much blood flow in the GI tract
Why does the PaO2 drop in hepatopulmonary syndrome?
Vasodilation leads to the inability of the alveoli to effectively oxygenate all the passing blood
*100% oxygen will correct
What is the pathophysiology behind hepatic encephalopathy?
Gut derived neurotoxins are not cleared due to hepatic insufficiency and bypass of the liver by collaterals
Toxins cross the BBB and lead to CNS changes
What is a specific sx seen with hepatic encephalopathy?
Asterixis with the "stop traffic" movement
What is the grading scale for hepatic encephalopathy?
Grade 0: No alteration in conciousness, intellectual function, or behavior
Grade 1: Trivial lack of awareness, euphoria or anxiety, short attention span
Grade 2: Lethary, disorientation, personality change, inappropriate behavior
Grade 3: Somnolence to semistupor, confusion, response to noxious stimuli
Grade 4: Coma, no response to noxious stimuli
What grade of hepatic encephalopathy warrents hospital admission?
Grade 2: lethargy, disorienation, personality change, inappropriate behaviour
What grade of hepatic encephalopathy warrents ICU?
Grade 3: somnolence to semistupor, confusion
Gade 4: coma, no response
What drug should be administered for hepatic encephlopathy?
Lactulose: nonabsorbable dissacharide. Lactic acid lowers the pH in the colon, conversion of ammonia to ammonium, which can be removed in the feces
What is an alternative to lactulose for hepatic encephalopathy?
What are the components of treatment for hepatic encepathlopathy
NO sleep meds
Look for infection
Give lactulose or rifaximin
What is the MC of acute liver failure in the US?
What is fulminant liver failure?
Acute liver failure with coagulopathy and encephalopathy
What is the main risk in fulminant liver failure?
Cerebral edema: cerebral herniation is the major cause of death