9 - Cirrhosis and Portal Hypertension Flashcards Preview

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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

31

"Other" Ascites Etiologies

Schistosomiasis
Non-Cirrhotic Portal Hypertension
Polycystic Liver Disease

32

Portal Hypertension to Ascites - Pathway

Cirrhosis
Splanchnic Arterial Vasodilation
Arterial Underfilling
Systemic Vasoconstriction
Renal Vasoconstriction

Also decreased blood albumin.
This leads to increased hydrostatic pressure and decreased oncotic pressure (all in vessels)
Increases lymph pressure
Lymph and the rest spills out into peritoneum
Initially resorbed by peritoneal surface of diaphragm (communicates with supradiaphragmatic lymphatics
Ascites formation exceeds reabsorption when HVPG > 10 mm HG

33

Ascites DUE TO PORTAL HTN - Characteristics

Serum - Ascites Gradient (SAG) > 1.1 g/dL
Transudate (Protein

34

Cirrhotic who develops ovarian cancer

SAG is STILL greater than 1.1!!

35

Ascites - Treatment

Treat underlying condition
Bedrest
Sodium & Fluid Restriction
Diuretics (Spironolactone, Furosemide, Amiloride, HCTZ, Metolazone, Zaroxyln)
Large-Volume Paracentesis
TIPS
Surgery (Leveen or Denver Shunt, Liver Transplantation)

36

Hepatohydrothorax

Almost always on the R side
Ascites in the chest
Maybe because IVC perforates diaphragm?
Ascites leaks through rents (

37

Hepatohydrothorax - Treatment

TIPS - for diuretic-refractory cases
Liver Transplantation
AVOID CHEST TUBES. Surgical repair usually not effective.

38

Spontaneous Bacterial Peritonitis

Infection of ascitic fluid
Independent of another intra-abdominal source
Monomicrobial
Enteric flora enters portal circulation, not cleared
OR
Translocation of bacteria from the gut

39

Spontaneous Bacterial Peritonitis - WBC

Ascites WBC > 500 or 250 with greater than 50% PMNs

40

Spontaneous Bacterial Peritonitis - Risk Factors

GI Bleeding/Hypotension
Advanced Liver Disease
Previous History

41

Spontaneous Bacterial Peritonitis - Organisms

E. Coli
Klebsiella
Pneumococcus
Enterococcus

42

Spontaneous Bacterial Peritonitis - Treatment

Broad Spectrum Antibiotics
Then narrow if culture results are known
Re-tap after 48 hours to confirm response to therapy
Volume expand (albumin)

43

Spontaneous Bacterial Peritonitis - Prevention

Early treatment of other infections
Prophylactic Antibiotics to GI bleeders
Oral Quinolones, TMP-Sulfa can prevent recurrence when given chronically

44

Spontaneous Bacterial Peritonitis - Presentation

Not typical! Not usually abdominal pain. They come in with something else!

If a cirrhotic is admitted to the hospital, you should perform a paracentesis, or you might miss it!!

45

If you've had Spontaneous Bacterial Peritonitis Once

You have to be on prophylaxis for the rest of your life!!

46

HepatoRenal Syndrome

Late stage cirrhosis

The compensatory local vasodilators protecting your kidneys in the early stages are starting to not work as well!

Decreased vasodilators
Increased vasoconstrictors

47

Early Cirrhosis

Decrease in SVR is compensated by Increased HR, CO, Stimulation of RAAS, ADH

48

Late Cirrhosis

Splanchnic circulation is resistant to Angiotensin II & ADH
Pressure must be maintained by local vasoconstriction

Leads to HepatoRenal Syndrome

49

HepatoRenal Syndrome

Etiology is an exaggeration of mechanisms involved in ascites formation.
Can happen in perfectly healthy kidneys!!

50

HepatoRenal Syndrome - Precipitants

GI Bleed
Nephrotoxins (NSAIDS, Aminoglycosides, Sepsis)
Iatrogenic (Diuresis, Paracentesis)

51

HepatoRenal Syndrome - Diagnosis

Euvolemic patient
But look like a pre-renal patient
Give fluid, but they STAY "pre-renal" appearing
Urine Output

52

HepatoRenal Syndrome - Treatment

TIPS
Glypressin
Terlipressin
Transplantation
Midodrine (increasing vascular resistance)
Octreotide (decreasing portal HTN)