Chronic Liver Failure I: Portal Hypertension, Ascites: Waters

Question 1

Describe the pathophysiology behind portal hypertension.

Answer 1

:: Increased blood flowing to intestines and stomach = more blood flows through portal vein = incr. pressure.
:: Cirrhosis of liver = incr. resistance = incr. pressure
:: Hepatic sinusoids become capillarized = incr. pressure
:: Fibrosis of liver w/ distortion of vasculature = incr. pressure

Question 2

Explain how the body changes its vasculature to compensate for portal hypertension.

Answer 2

Develops collateral circulation to get around liver.
Venous collaterals form from distal esophagus all the way to the rectum (esophageal varices to hemorrhoids).
- Anterior collaterals via umbilical vein
- Posterior collaterals via retroperitoneal veins, splenorenal shunts

Question 3

Why would pts with portal HTN have a low platelet count?

Answer 3

Blood fills spleen when attempting to get around liver, platelets get trapped in spleen.

Question 4

How do you tx hemorrhage secondary to an esophageal varix or other ruptured, high pressure venous bleed?

Answer 4

Volume resuscitation.
Correct coagulopathy
Splanchnic vasoconstriction- Vasopressin and somatostatin to inhibit systemic vasodilation of glucagon.
Decr. blood flow via collaterals

Question 5

Describe treatment used to prevent re-bleeding after esophageal varix rupture.

Answer 5

Endoscopic therapy to sclerose or band the varices.

When pt is stable again:
B-blockers to reduce BP, to prevent subsequent rupture.
Transjugular intrahepatic portosystemic shunt
Liver transplant
Surgical portosystemic shunt- high risk

Question 6

Child Pugh score. Quick overview.

Answer 6

Takes into account:
Albumin
PT/INR
Bilirubin
Ascites
Encephalopathy

Graded A->C. A good, C very bad.

Question 7

Describe the factors contributing to ascites.

Answer 7

Incr. resistance to portal venous flow
Incr. blood flow to portal vein
Incr. lymphatic flow
Leakage of lymphatic flow from liver and intestines

Question 8

What are the kidneys doing during ascites?

Answer 8

Trying to retain more Na+, incr. Renin-Angiotensin activity, trying to maintain renal blood flow.
This is bad overall bc, it incr. BP –> ascites.

Question 9

What are some complications of ascites?

Answer 9

Hepatic hydrothorax

Spontaneous bacterial peritonitis

Question 10

How do you tx ascites?

Answer 10

Sodium restriction
Diuretics
Tx liver dz
Large volume paracentesis- MUST admin IV albumin concurrently