week 6 7 - clinical syndromes of cirrhosis

Question 1

4 collateral pathways involved in portal venous system

Answer 1

(portocaval anastomosis)

eosophageal and gastric venous plexus
umbilical vin - left protal vein to the epigastric venous system
retroperitoneal collateral vessels
haemorrhoidal venous plexus

Question 2

what may happen to the collateral pathways in portal hypertension

Answer 2

they may become engorged,dilated, varicosed and rupture

Question 3

define portal hypertenson

Answer 3

> 8 mmHg (5-8 normal range)

a pressure gradient between portal vein and hepatic vein greater than 5mmHg

Question 4

2 factors leading to portal hypertension

Answer 4

increased resistance to portal flow (r) and increased portal venous inflow (q)

P = QR

Question 5

portal hypertension can be classified as prehepatic or intrahepatic , outline each

Answer 5

pre- blockage before liver (portalvein thrombosis, occlusion secondary to congenital portal venous abnormalities)

intra - distortion of liver architecture, either

• presinusoidal (schistomiasis, parasite infectioin - non-cirrhotic portal hypertension)
• postsinusoidal (cirrhosis, alcoholic, fibrosis, steatohepatitis)

Question 6

hepatic carcinogenesis is

Answer 6

recurrent hepatocyte death (and regeneratioN)

Question 7

difference in compensated and decompenated cirrhossis

Answer 7

compensated - clinical normal, lab test/imaging abnormalities, Portal HT may be present

decompensated - liver failure, acute-on-chronic, end stage liver disease

Question 8

associated signs of compensated cirrhosis

Answer 8

spider naevi
palmar erythema 
clubbing 
gynaecomastia 
hepatomegaly/splenomagly (maybe) 
or none

Question 9

associated signs of decompensated cirrhosis

Answer 9

jaundice
ascites
enceophalopathy
bruising

Question 10

recommended nutrition intake for decompensated cirrhosis

Answer 10

energy - 35-40 kcal/kg
protein - 1.2-1.5g/kg
small frequent meals/snacks to reduce fasting gluconeogenesis/muscle catabolism
vitB supplements may be necessary (esp if alcoholic)
1000mg Calcium 20uq Vit D

Question 11

refeediing syndrome

which patients more at risk

Answer 11

malnourished overnourished (holocaust) 
alcoholics

Question 12

how does ascites happen

Answer 12

cirrhosis/portal hypertension causes peripheral arteriolar vasodilation - reduced resitance and reduced arteriolar blood volume
this activates vasoconstriction
- increases portal presure/co/hr/plasma and blood volumes (na retention)/vascular resistance
fluids pished out

Question 13

how is ascites diagnosed on examination

which imaging can also be used to confirm

Answer 13

shifting dullness

ultrasound

Question 14

how is ascites treated

Answer 14

improve underlying liver disease
treat infection if there
if Na overload - reduce salt intake, maintain nutrition and no NSAIDS

spinolactone first
surgery - paracentesis/TIPSS/transplantation

Question 15

in new ascites it is appropriate to increase sprinolactone (water diuretic) however if recurrent what is also given

Answer 15

loop diuretic (furosemide)

Question 16

when is paracentesis carried out on an ascites patient 3

Answer 16

if at risk of infection
signs of encephalopathy
hypovolaemia

Question 17

define spontaneous bacterial peritonitis

Answer 17

translocated bacterial infection of ascites

Question 18

treatment for SBP

Answer 18

mild - co-trimoxazole
severe - piperacilin/tazobactam

if vascular instability - terlipressi

Question 19

diagnosis of SBP

Answer 19

ascites tap

if neutrophil count ?250 cells/mm3

Question 20

liver flap is seen in

Answer 20

encephalopathy

Question 21

ammonia is the cause of encephalopathy, as is distrubs the neurotransmitters in the brain. This does not occur in skeletal muscle, why

Answer 21

skeletal able to metabolise ammonia to glutamine

Question 22

drug given for encephalopathy

Answer 22

rifaximin (also used to treat travellers diarrhoea, IBS)

Question 23

transplantation for liver disease is considered on events, LFT and quality og liife, give examples of when each may lead to consideration

Answer 23

event

• ascites - resistant/SBP
• variceal bleed

LFT
-bilirubin,albumin,PT high after therapy

quality - if persistant symptoms of

• itch
• lethargy
• spontaneous encephalopathy

Question 24

patients requir a UKELD score of …. to be listed for elective liver transplant unless they have 2

Answer 24

> /=49

unless Variant syndrome (diuretic resistant ascites, hepatopulmonary/ chronic hepatic enceophalopathy intractable pruritis/ polycistic liver, familial amyloidosis/ primary hyperlipidaemia) Hepatocellular carcinoma