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Internal Medicine pt.1 > Cirrhosis > Flashcards

Flashcards in Cirrhosis Deck (17)
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1
Q

What will be found on investigation of a liver cirrhosis patient?

A
  • low hemoglobin (N= 14 - 16)
  • high MCV (N= 80 - 100)
  • thrombocytopenia (N= 150 - 400)
  • total bilirubin increased (N = 0 - 6)
  • direct bilirubin increased (N = 0 - 0.3)
  • AST/ALT ratio 2:1
  • PT increased (N = 11 - 13.5)
  • INR (N = 0.8 - 1.1)
  • ammonia high (N = 11 - 32) -> encephalopathy
2
Q

What are the types of anemia?

A

MICROCYTIC
MCV < 80: iron deficiency OR thalassemia
- if microcytic anemia if found with liver disease -> look for bleeding

MACROCYTIC
MCV > 100
- megaloblastic: B12 OR folate deficiency
- non-megaloblastic: chronic liver cirrhosis, alcoholic, hypothyroidism

3
Q

What is the pathogenesis of liver cirrhosis?

A
  • repetitive cell injury
  • irreversible fibrosis
  • loss of liver cell failure
4
Q

What is the most common age group where death due to liver cirrhosis occurs?

A

5th to 6th decades of life

5
Q

What are the causes of liver cirrhosis?

A

HEPATOTOXICITY

  • long standing alcohol use
  • medications (acetaminophen, methotrexate..)

HEPATITIS

  • viral (hepatitis B, C, D)
  • primary biliary cirrhosis
  • primary sclerosing cholangitis
  • autoimmune hepatitis
  • parasitic infections

METABOLIC

  • NASH
  • hemochromatosis
  • Wilson’s disease (due to seroplasmin deficiency)
  • a1-antitrypsin deficiency

HEPATIC VEIN CONGESTION

  • Budd-chiari syndrome
  • Cardiac cirrhosis
6
Q

What are the dermal features of cirrhosis?

A
  • pruritus
  • jaundice
  • telangiectasia -> spider angiomata
  • caput medusa -> portal hypertension
  • palmar erythema -> hyperestrogenemia
  • petechiae & purpura -> thrombocytopenia
  • white nails (leukonecya) -> hypoalbuminemia
  • nail clubbing
7
Q

What are the GI & hormonal features of cirrhosis?

A

GI

  • nausea, vomiting
  • hepatosplenomegaly
  • ascites

Hormonal (high estrogen)

  • gynecomastia
  • hypogonadism
8
Q

What are the other random symptoms of liver cirrhosis?

A
  • asterixis
  • fetor hepaticus
  • dupuytren’s contracture
  • peripheral edema (hypoalbuminemia)
  • esophageal varices
  • hemochromatosis -> dark bronze skin + diabetes
  • Wilson’s disease -> neurological/psychiatric symptoms (parkinsonism & personality changes)
  • alpha-1 antitrypsin deficiency -> lung emphysema
9
Q

What is the significance of a CBC in liver cirrhosis?

A
  • microcytic anemia -> chronic blood loss
  • macrocytic anemia -> B12 or folate deficiency
  • thrombocytopenia -> due to hyperslpenism due to portal hypertension & decreased thrombopoietin production from the liver
10
Q

What is the effect of cirrhosis on the LFTs?

A
  • AST > ALT -> if not more than 500 anything other than hepatitis (alcoholic) - if 1000s hepatitis
  • bilirubin is initially normal or increased
  • increased GGT, alkaline phosphatase, GDH, & ammonia
  • decreased albumin
  • increased PT & INR
11
Q

What labs should be done to determine the etiology of cirrhosis?

A
  • HEPATITIS -> anti-HBs, anti-HBc, HBsAg, & anti-HCV
  • a1 ANTITRYPSIN DEFICIENCY -> serum a1- antitrypsin
  • HEMOCHROMATOSIS -> serum iron, ferritin
  • WILSON -> serum & urine copper, serum ceruloplasmin
  • AUTOIMMUNE -> hypergammaglobulinemia in serum protein electrophoresis, ASMA
  • PBC -> + anti-mitochondrial antibodies (AMA or AMA-M2), increased alkaline phosphatase, increase bilirubin
  • PSC -> GGT, alkaline phosphatase, bilirubin, pANCA increased + COLONOSCOPY
12
Q

How is liver cirrhosis treated?

A
  • treat underlying condition
  • avoid hepatotoxic substances (alcohol, paracetamol, NSAID)
  • routine vaccinations
  • balanced diet with no protein restriction
  • propranolol or nadolol -> to decrease portal HTN
  • spironolactone & furosemide -> to manage ascites & edema in patients with hypoalbuminemia
  • treat complications
13
Q

What are the complications of liver cirrhosis & how are they treated?

A
  • decompensated cirrhosis -> treat by relieving the stress & flushing out the extra fluid
  • spontaneous bacterial peritonitis -> treated by IV ceftriaxone + albumin & oral FQ for life
  • esophageal variceal hemorrhage -> treat by octreotide & band ligation & antibiotics until no more bleeding (ceftriaxone)
  • hepatic encephalopathy -> treat using lactulose +- rifaximin or TIPS
  • hepato renal syndrome -> treat by midodrine, octreotide, & albumin
  • portal vein thrombosis -> treat by excision of thrombus +- anticoagulation (high risk of bleeding)
  • portopulmonary hypertension -> treated by long term O2 or liver transplant
  • HCC -> screen by US every 6 months
14
Q

How is spontaneous bacterial peritonitis diagnosed?

A

pericentesis of ascitic fluid will show granulocytes > 250

  • commonly E. coli, helicobacter, Klebsiella
15
Q

What are the risk factors for hepatic encephalopathy?

A
  • infection
  • non adherence to meds
  • constipation -> patient must defecate 2 - 3 times a day
  • dehydration
  • GI bleed
  • portal vein thrombosis
16
Q

What is the cause of hepato-renal syndrome?

A

decreased renal blood flow leads to kidney injury -> increased creatinine by > 50%

17
Q

What is the cause of portopulmonary hypertension?

A

high cardiac output in advanced liver disease -> wall shear stress in pulmonary vasculature

  • causes dyspnea & hypoxemia
  • diagnosed by right heart catheterization