JH IM Board Review - Complications of Liver Disease I

Question 1

Definition - Hepatic FIBROSIS:

Answer 1

A potentially REVERSIBLE wound healing response characterized by an accumulation of extracellular matrix made up of collagen fibrils.

Question 2

Definition - Cirrhosis:

Answer 2

Defined by:

1. Global hepatic fibrosis.
2. Nodule formation.
3. Reduced hepatic synthetic function.

Question 3

Overview of cirrhosis - Pathophysiology:

Answer 3

1. Chronic hepatic inflammation and injury result in hepatic stellate cell activation and endothelial cell damage.
2. Activated stellate cells produce collagen (fibrosis) with subsequent vascular and organ contractions.

Question 4

Definition of portal HTN:

Answer 4

Portal vein pressure of greater than 8mmHg.

==> MC and most morbid consequence of liver disease and cirrhosis.

Question 5

Direct portal pressure measurement is highly invasive - Measurement of HVPG (hepatic venous pressure gradient):

Answer 5

HVPG >10 mmHg ==> Development of varices.

HVPG >12 mmHg ==> Complications of portal HTN (eg ascites, variceal hemorrhage).

Question 6

Classification of portal HTN - Postsinusoidal:

Answer 6

Obstruction DISTAL to hepatic sinusoid:

1. EXTRAhepatic (eg IVC obstruction, Budd-Chiari syndrome, RHF).
2. INTRAhepatic (eg Venoocclussive disease, alcoholic central hyaline sclerosis).

Question 7

Classification of portal HTN - Presinusoidal:

Answer 7

Obstruction PROXIMAL to hepatic sinusoids:

1. Prehepatic (eg splanchnic AV fistula, splenic vein thrombosis, portal vein thrombosis).
2. Hepatic (eg schistosomiasis, sarcoidosis, myeloproliferative disorders).

Question 8

Classification of portal HTN - Sinusoidal:

Answer 8

1. Cirrhosis.

2. Acute alcoholic hepatitis.

Question 9

Pts with cirrhosis have an …% annual risk of developing varices.

Answer 9

8%. (+ 8% annual rate of progression from small to large varices).

Question 10

Predictors of variceal hemorrhage:

Answer 10

1. Size of varices.
2. Child B or C cirrhosis.
3. Red “wale” sign seen on endoscopy.

Question 11

Varices screening:

Answer 11

Endoscopy is the key to the diagnosis of varices.

==> Screening every 1 to 3 years is recommended for pts with cirrhosis.

==> Frequency of screening increases with severity of liver disease.

Question 12

Varices - Tx - Primary management of varices:

Answer 12

Non selective beta-blockers (eg propranolol, nadolol) ==>

Recommended for the 1o prevention of bleeding in SMALL varices with increased risk of bleeding (Eg Child B and C, red wale marks) and in ANY medium or large varices.

Question 13

Non selective beta-blockers are NOT recommended for which varices?

Answer 13

SMALL varices without increased risk of bleeding.

==> 1o prophylaxis to prevent the development of varices.

Question 14

Role of Serial Endoscopic Variceal Ligation (EVL) in varices:

Answer 14

For 1o prevention of bleeding in MEDIUM or LARGE esophageal varices, particularly if a patient cannot tolerate beta-blockers.

Question 15

General management of acute variceal hemorrhage consists of:

Answer 15

1. Intravascular volume resuscitation.
2. Maintaining Hb NO HIGHER THAN 8g/dL (to avoid unwanted portal pressure elevation).
3. Somatostatin analogues ==> To reduce splanchnic blood volume.
4. Short-term phophylactic abx.

Question 16

3 measures for acute variceal bleeding:

Answer 16

1. Urgent endoscopic evaluation and therapy.
2. TIPS for uncontrolled or recurrent variceal hemorrhage despite endoscopy.
3. Balloon tamponade can be an effective but temporary (less than 24h) control of hemorrhage.

Question 17

After recovering from acute variceal hemorrhage, 2o prophylaxis using …?

Answer 17

1. Non selective beta-blockers.
2. Serial Endoscopic Variceal Ligation (EVL) is recommended.
3. If bleeding still occurs, consider TIPS.

Question 18

Variceal bleeding - What is the goal of HVPG?

Answer 18

Less than 12mmHg or at least 20% below baseline levels.