55. Cirrhosis and portal hypertension Flashcards Preview

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Flashcards in 55. Cirrhosis and portal hypertension Deck (39)

Cirrhosis - histology

end-stage liver damage --> diffuse bridging fibrosis abd regeberative nodules disrypt normal architercture of the liver


Cirrhosis - fibrosis is mediated by / increases the risk of

-TGF-β from stelate cells
- hepatocellular carcinoma


etiology of cirrhosis ( and MCC with proportion in US)

1. alcohol (60-70%)
2.nonalcoholic steatohepatitis
3. Chronic viral hepatitis
4. autoimmune hepatitis
5. biliary disease
6. genetic / metabolic disorders


Portal hypertension - definition and etiology ( and MC in west)

increased pressure in portal venous system. Etiologies
1. cirrhosis ( mC in west)
2. vascular obstruction ( portal vein thrombosis, Budd Chiari syndrome
3. schistosomiasis


Cirrhosis manifestation - integumentary system

1. jaundice
2. spider angiomas
3. palmar erythemas
4. purpura
5. petechiae


Cirrhosis manifestation - nervous system

1. hepatic encephalopathy
2. asterixis ( flapping tremor)


Cirrhosis manifestation - hematologic system

1. thrombocytopenia
2. anemia
3. coagulation defects


Cirrhosis manifestation - GI system

1. anorexia
2. nausea
3. vomiting
4. dull abdominal pain
5. fetor hepaticus ( portosystemic shunting allows thiols to pass directyly into the lungs)


Cirrhosis manifestation - Metabolic system

1. hyperbilirubinemia
2. hyponatremia
3. hypoalbuninemia


Cirrhosis manifestation - Reproductive system

1. testicular atrophy
2. gynecomastia
3. amenorrhea


Cirrhosis manifestation - cardiovascular system

1. Cardiomyopathy
2. peripheral edema


Cirrhosis manifestation - effects of portal hypertension

1. esophageal varices ( --> hematemesis)
2. Gastric varices (--> melena)
3. splenomegaly ( --> hypersplinism)
4. caput medusa
5. ascitis
6. anorectal varices ( hemorrhoids)
7. hepatorenal syndrome


Cirrhosis manifestation - Na+ ?



Enzyme release liver damage

1. AST ( aspartate aminotranferase)
2. ALT ( alaline aminotranferase(
3. ALP ( Alkaline phosphate
4. γ- glutamyl transpeptidase ( γ- GT)


AST +ALT normal levels

1. AST ( asparte aminotransferase) --> 8-20 U/L
2. ALT ( alaline aminotransferase ) ---> 8-20 U/L


AST vs ALT according to levels in pathological situations

increased in most liver disease with ALT > AST increased in alcoholic liver disease with AST > ALT (2:1) if AST> ALT in nonalcoholic disease ---> pogression to advanced fibrosis or cirrhosis


liver disease AST > ALT ?

1. alcoholic liver disease (2:)
2. in nnalcoholic disease --> progression to advanced fibrosis or cirrhosis


ALP ( Alkaline phosphate ) is increased in

1. Cholestasis ( eg. biliary obstruction)
2. Bone disease
3. Infiltrative disorders
4. chronic kidney disease
5. liver infiltrative diseases
6. metastasis to bone or liver
7. seminoma ( placental)


γ-Glutamyl transpeptidase ( γ-GT) increased in

-increased in various liver and biliary disease ( just as ALP but not in bone disease
-associated with alcohol use


Functional liver markers

1. Bilirubin
2. Albumin
3. Prothrombin
4. Platelets


Functional liver markers - bilirubin is increased in

increased in
1. various liver diseases ( eg. biliary obstruction, alchoholic or viral hepatitis, cirrhosis)
2. hemolysis


Functional liver markers - albumin

decreased in advanced liver disease


Functional liver markers - platelets ( and mechanism)

1. decreased in advanced liver disease ( low thrombopoietin , liver sequestration)
2. decreased in portal hypertension ( splenomegaly / splenic sequrstration )


Functional liver markers - prothrombin ( and mechanism )

increased in advanced liver disease ( low production of clotting factors


• During an autopsy, a 52-year-old man from the United States is found to have a shrunken, nodular liver. What is the most likely etiology?

Alcohol (responsible for 60–70% of cirrhosis in the United States)


• Esophageal varices and caput medusae are caused by ____ (pathologic state) and are partially alleviated by ____ shunts.

Portal hypertension; portosystemic


• A patient with musty-smelling breath presents to the ED with confusion and asterixis. What skin findings do you expect on exam?

Common skin findings in liver failure are jaundice and spider nevi (the musty breath is fetor hepaticus) & may see caput medusae, edema


• A patient with melena is found to have esophageal varices. Where else in the GI tract are you concerned for bleeding?

The stomach, due to bleeding peptic ulcers (or may be caused by portal hypertension)


• Name at least three direct effects of portal hypertension.

Splenomegaly, caput medusae, ascites, esophageal varices with hematemesis, peptic ulcers, anorectal varices, portal hypertensive gastropathy


• An alcoholic has cirrhosis due to liver failure. What do you expect to find on eye exam?

Scleral icterus


• While seeing a patient with known cirrhosis, you cannot help but notice his musty breath. What is this called?

Fetor hepaticus


• Visible dilated capillary proliferation within the skin secondary to the effects of liver failure and cirrhosis is called what?

Spider nevi


• A man with liver failure also complains of gynecomastia and testicular atrophy. How did this likely develop?

Due to an increase in estrogen


• A patient with cirrhosis has a coarse, flapping tremor of the hands. What is this called?



• A cirrhotic patient should be cautioned about what kind of hematologic abnormality(ies) due to her liver cell failure?

Bleeding tendency (decreased production of clotting factors, increased prothrombin time) and anemia


• Why do patients with cirrhosis have an increased tendency to bleed?

Liver cell failure decreases production of prothrombin and clotting factors


• Is the bleeding tendency in cirrhosis considered an effect of portal hypertension or an effect of liver cell failure?

Liver cell failure (it is due to the inability to synthesize clotting factors)


• Is the ankle edema of cirrhosis considered an effect of portal hypertension or an effect of liver cell failure?

Liver cell failure (it is due to the inability to synthesize albumin resulting in lack of oncotic pressure)


• What is cirrhosis?

Cirrhosis is defined as diffuse fibrotic and nodular regeneration that disrupts the normal architecture of the liver

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