9 - Cirrhosis and Portal Hypertension Flashcards Preview

GI / Hepatology > 9 - Cirrhosis and Portal Hypertension > Flashcards

Flashcards in 9 - Cirrhosis and Portal Hypertension Deck (52)
Loading flashcards...
1

What is cirrhosis?

End stage of chronic liver disease
Regenerative nodules surrounded by fibrous septa
Disruption of architecture of liver

2

Common etiologies of Cirrhosis

Alcohol
Viral Hepatitis
NAFLD
Genetic/Metabolic Diseases

3

Pathway to Cirrhosis

Injury
Inflammation --> Fibrosis
Resolution OR Cirrhosis ---> HCC

4

Forms of Injury Leading to Cirrhosis

Viral Hepatitis
Alcohol
Steatohepatitis
PBC
???????

5

Cirrhosis Pathogenesis

Stellate cells sit in space of disse and store Vita A
During cirrhosis, they transform into myofibroblasts and make and deposit collagen

Stimulated by inflammation, cytokines and toxins

Collagen I & III are deposited in all portions of the lobule

Ultimately architecture and vasculature of hepatocytes are disrupted.

6

Complications of Cirrhosis

Portal Hypertension

Varices
Ascites
Hepatohydrothorax
Spontaneous Bacterial Peritonitis
Hepato-Renal Syndrome

7

Anatomy - 2 sources of blood flow to liver

Hepatic Artery
Portal Vein

8

Pre-Hepatic Hyptertension

Portal Vein Thrombosis
Splenic Vein Thrombosis

9

Intra-Hepatic Portal Hypertension

Pre-Sinusoidal (Schistosomiasis)
Sinusoidal (Cirrhosis)
Post-Sinusoidal (Veno-occlusive disease) - Bush Tea or medications

10

Post-Hepatic Portal Hypertension

Budd - Chiari:
Obstruction of vena cava or hepatic vein

11

Liver Blood Flow - High Flow

Mesenteric Vessels feeding the portal vein

12

Liver Blood Flow - Low Pressure

Sinusoidal network

13

Effects of Cirrhosis

Fixed scarring of liver
Sinusoidal blood vessels - Increased resistance
This causes increased pressure in portal vein
However, portal vein FLOW actually increases as well

14

Why does portal vein flow increase in response to cirrhosis, even though the pressure is increased due to resistance?

Cytokines (like TNF) are released in response to the increased sinusoidal resistance and mildly increased portal vein pressure.
This leads to nitrous oxide release
NO release leads to splanchnic bed dilatation
This leads to increased splanchnic flow

15

Systemic effects of cirrhosis

High cardiac output
Low SVR

16

Catheter in Hepatic Vein - Deflated Ballooon

Measures what?

Free HV Pressure

17

Catheter in Hepatic Vein - Inflated Ballooon

Measures what?

Portal Vein Pressure

18

Normal PV - HV pressure gradient

Less than 7

19

Significant PV - HV pressure gradient for Portal Hypertension

Greater than 10

20

Cirrhosis - Effects on Blood Flow - Portal Hypertension

Fibrosis restricts blood flow, increases portal vein pressure
Collaterals acquire increased pressure, affecting spleen, esophagus, stomach (varices), gastropathy
Ascites due to fluid shift into the peritoneum
Shunting of blood from liver decreases metabolism of "toxins"
Portal bacteremia not cleared induces peritonitis

21

Physical Exam Findings of Cirrhosis

Telangiectasias
Varices

22

Esophageal Varices

Sequellae of Portal Hypertension
Risk of bleeding proportional to size and degree of portal hypertension
Graded in increasing size I, II or III
Even with optimal therapy, risk of death from an esophageal bleed is greater than 20%

23

Gastric Varices

Also from portal hypertension
Near Gastro-Esophageal Junctures

24

Portal Gastropathy

Gastropathy from portal hypertension
Oozing capillaries
Leads to anemia in some cirrhotic patients

25

Esophageal Varices - Emergency

Hypotensive
Tachycardic

26

Esophageal Varices - Acute Treatment

Stabilize Hemodynamics (Give Volume)
Decrease Portal Pressure (Octreotide Acutely - IV, Somatostatin)
Locally stop bleeding (Banding)
Prophylactic Antibiotics

27

Esophageal Varices - Chronic Treatment

Non-Selective Beta Blockers (Propanolol, Nadolol, Carvedilol)
Banding Ablation
TIPS
Surgical Shunt
Transplantation

28

TIPS

Transjugular Intrahepatic Porto-Systemic Shunt
From Portal Vein to IVC
A good portion of the portal venous flow bypasses liver entirely!

Complication: 20% develop hepatic encephalopathy

29

Surgical Shunts

Don't get used

30

Ascites DDX

Portal Hypertentsion
Peritoneal Inflammation
Ovarian Cancer
Nephrogenic Ascites (Nephrotic Syndrome)
Pancreatic Ascites
Other