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gi, liver, kidney > Cirrhosis > Flashcards

Cirrhosis Flashcards

1
Q

Which AI hep is more severe

A

Type 2

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2
Q

Stages of cirrhosis

A

Stage 1
Stage 2 - varices, no ascites
Decompesnation event (HVPG >12mmHg)
Stage 3 - bleeding
Stage 4 - first non bleeding decompensation - ascites, HE, jaundice
Stgae 5 - second decompensation

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3
Q

How does portal HPTN occur

A

→ Liver failure +splanchic vasodilation → increased portal blood inflow - increased portal pressure → varices → bleeding

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4
Q

Cirrhosis effects on systemic circulation

A
  • Vasodilation
  • Hypotension
  • Increased plasma volume
  • Increased cardiac index

→ hypovolaemia→ RAAS + Na retention → ascites

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5
Q

What are signs of decompensation in cirrhosis

A

Jaundice
Increasing ascites
Hepatic encephalopathy
Renal impariment/hypovolaemia
Signs of spesis

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6
Q

What can precipitate a decompensation in liver disease

A

GI bleeding
Infection/sepsis
Alcohol Drugs - opiates, NSAIDs
HCC
Portal vein thrombosis
Dehydration
Contipation - encephalopathy

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7
Q

How analyse asciic fluid and when done

A

Paracentesisi
New ascites, cirrhotic patient with ascites in hospital

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8
Q

What is SAAG

A

Albumin in serum:ascites

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9
Q

What does a SAAG >11 suggest

A

ascites due to portal HPTN

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10
Q

Causes of ascites SAAG >11

A

Portal HPTN
Cardiac failure
Portal vein thrombosis
Hypothyroidism

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11
Q

Causes of ascites where SAAG <11

A

Pertionneal carcinomastosis
Peritonneal TB
Panceratitis
Bowel perforation
Nephrotic syndrome

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12
Q

What get in SBP

A

Fever, abdo pain, renal impairment or asymptomatic

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13
Q

What find in ascitic tap in SBP

A

Polymorphonucear cells >250m3
Neutrophils 0.25x109

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14
Q

Treatment SBP

A

Anitbiotics - test for sensitivities - co-amoxilav or ciprofloxacin

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15
Q

Ascites management

A

Na restrict, diuretics #
TIPS
Large volume paracentesis
Liver transplant

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16
Q

Criteria for diagnosis of hepatorenal syndrome exclusion

A

Cirrhosis, ALF
Criteria for fialing kidneys urine output/creatinine >50%
No full or partial response after 2 days diuretic withdrawal + volume expansion with albumin
Absence of shock
No current or recent nephrotoxic drugs
Absence of parenchymal disease - proteinuria, haematuria, urinary biomarkers
FeNa <0.2% (renal vasoconstriction)

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17
Q

Kidney crtieria for hepatorenal syndrome - class 1

A

Absolute increase in sCR >0.3 mg/dL in 48 hrs
Urinary output <0.5ml/kg BW >6 hrs
% increase in sCR >50% using last available value of outpatient sCr within 3 months

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18
Q

Resus for a variceal bleed

A

Intubation consider
High flow O2
IV access
Blood transfusion
Antibiotics
Terlipressin/somatostatin
If fail -> balloon
tamponade
If unstable immediate gastroccopy

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19
Q

After resus management of variceal bleed

A

Gastroscopy within 24 hours - separate oesophageal vs gastric origin

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20
Q

Oesophageal variceal bleed management

A

Band ligation
Success -> sedonary prophylaxis after 5 days

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21
Q

Secondary prophylaxis varcies oesophageal

A

VBL + non selective beta blcker

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22
Q

Who do a TIPS within 72 hrs of bleed in (after haemostasois)

A

Childs pugh B + active bleed
Childs pugh C + ,14 - 1b, grade B

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23
Q

Gastric variceals treatment

A

Cryanoacrylate injection or trombin
Consider SBB
TIPS if large or multiple barices

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24
Q

First line for rebleed varices

A

Salvage TIPS
Balloon tamponae until can do a TIPS

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25
Q

Alternative to TIPS

A

Balloon occulded retrograde transvenus obliteration or surgical shunt

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26
Q

How monitor if no varices on endoscopy

A

Re endosocpe in 2-3 years

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27
Q

What do if Grade I varices on endoscopy

A

Re-endsocope in 1 year

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28
Q

What do if grade II or III varices - or red signs

A

Non selective beta blocker
If intolerant -> band ligation
Cryanocylate injection if needed

29
Q

When do splenectomy or splenic artery embolisation in cirrhosis

A

L sided portal HPTN or splenic vein thrombosis

30
Q

How does vasopressin work

A

increases peripheral resistance, decreases splanchic blood flow
Has to be given IV

31
Q

Antibiotic options for GI bleed

A

Cephalosporin, quinolones, betalactam, carbepenam

32
Q

When refer for TIPS

A

After failure of second therapy for varices

33
Q

What NSBB given for variceal bleed prophylaxis

A

Propanolol 40mg 2 x daily
Also carvediol, nadolol

34
Q

When discontinue NSBB in cirrhosis

A

SBP, renal impairment, hypotnesion
Offer VBL if CI

35
Q

When is there no need to repeat endoscopy in cirrhosis

A

Already on NSBB and no findings

36
Q

What do if TIPS not feasible in CP A/B

A

Shunt surgery

37
Q

What is a red sign on varices on endoscopy

A

evidence of bleeding already or high risk bleed

38
Q

Grading of varices

A

1 - narrow, flatten easily with air
2 - broader and flatten with difficulty or dont
3-
4-

39
Q

Why does cirrhosis cause HE

A

Increased gut dervied toxins in blood noramlly cleared by liver stay in as blood is shunted away from passing through + liver cant process as well

40
Q

How to tell if HE is acute or chronic

A

Cerbral oedema - acute liver failure

41
Q

Triggers for HE

A

Decompensating events
Infection
GI bleed
Electrolyte disturbance
Constipation
Sedative drugs

42
Q

Mangement of Hepatic encephalotpathy

A

Treat underlying cause
Oral lacutalose - aim 2-3 stools/day
Phosphate enemas
Rifazamin

43
Q

When give rifaxamin in HE

A

if persistent />1 admission

44
Q

Grade 1 HE

A

Mild confusion, euphira, aniety, depression, reversed sleep syndrome, slurred speech

45
Q

Grade 2 HE

A

Drowsy and lethargi, gross deficits in mentla tasks, moderate confusion

46
Q

Grdae III vs IV HE

A

III - somnolent but arousable, severe confusion, inability to perform mental tasks
IV - coma (IVa) with (IVb) without response to painful stimuli

47
Q

Screening for malnutrition in cirrhosis when do

A

BMI <18.5
Childs pugh score C

48
Q

How assess nutritonal status in cirrhosis

A

Muscle mass - CT, DEEA, US
mUSCLE fucntion - hand grip
Global physical performance - time up and 6 min walk test
Educate patient on imporatnce - - 30 kcal/BW/day, 1.5-2g protein/BW

49
Q

Areas assessed in childs pugh score

A

Encephalopathy (none, minimal, coma)
AScites (absent, controlled, refractory)
Bilirubin <34, - , >51
Albumin >35, -, <28
PT <4, -, .6

50
Q

What is the UKELD score

A

Calculation of need for transplant in UK
Include bilirubin, INR, creatinine, Na

51
Q

Surveillance for HCC in cirrhotic/high risk patients

A

every 6 monts US and alpha fetoprotein

52
Q

Chemoprevention strategies HCC

A

Antivirals
antiinflams
Antifirbtoics
Metabloci disease treat
Molecular targeted therapies

53
Q

Treatment options for early HCC

A

Ablation, resection, transplant
>5 year survival

54
Q

Treatment for intermediate HCC

A

Chemoembolisation
Preserved liverfunction but unresectable

55
Q

Treatment for advanced HCC

A

Liver function, portal/intrahepatic spread
Systemic therapy
PS1-2
10 month survival

56
Q

What is terminal stage HCC

A

Not transferable
End stage liver function
PS3-4

57
Q

When is surgery possible with HCC

A

Grade 0 - single lesion <2cm
early stgae - solitary OR 2-3 nodules <3cm
If solitary -> resection
If transplant candidate, transplant
If neither -> ablation

58
Q

UK liver transplant indications - score level cirrhosis, HCC

A

Chronic liver failure - UKELD >49
HCC up to 5 tumours <3cm or single up to 5/7cm if stable
Acute liver failure

59
Q

How does variceal bleeding present

A

Haematemesis - blood vomit, bright red or coffee ground
Melaena - black tarry dark stools
Severe hypotnesion

60
Q

Clotting agents may need transfusing in varcieal bleed

A

correct clotting: FFP, vitamin K, platelet transfusions

61
Q

Do endosopy or terlipressin and antibiotics first in variceal beed

A

Terlipressina nd quinolones first

62
Q

Common complication of TIPS

A

Uraemia-> excerbation of hepatic encephalopathy

63
Q
A
63
Q

Risk factors for HCC

A

CIRRHOSIS - hepatitis, alcohol, haemoachromatosis, PBC
Alpha 1 antitrypsin deficiency
Glycogen storage disease
Hereditary tyrosinosis
Aflatoxin
Drugs - COCP, anabolic steroids
Porphyria cutanea tarda
Male
DM, metbaolic syndrome

64
Q

Presentation of HCC

A

Decompesnation of liver disease
Jaundice, ascites, RUQ pain, hepatomegaly, pruritis, splenomegaly
Presents late

65
Q

Referral crtieria HCC

A

2 week wait US if upper abdo mass - hepatomegaly

66
Q

Medication for HCC?

A

Sorafenib - multikinase inhibitor

67
Q

What groups screen with US + AFP

A

patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis
men with liver cirrhosis secondary to alcohol

gi, liver, kidney (50 decks)

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