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Flashcards in Cirrhosis Deck (19):
1

Physical exam findings in Cirrhosis

  • jaundice
  • spider angiomata
  • left lobular enlargement
  • caput medusae
  • ascites
  • muscle wasting
  • splenomegaly

2

Laboratory findings in Cirrhosis

  • hypoalbuminemia
  • prolonged prothrombin time
  • hyperbilirubinemia
  • portal hypertension/hypersplenism ==> low platelet count

3

Radiologic findings in Cirrhosis

  • nodular liver
  • caudate lobe hypertropy
  • ascites
  • splenomegaly
  • venous collaterals
  • hepatocellular carcinoma

4

Mechanism of Portal Hypertension

  • static and dynamic causes of increased intrahepatic vascular resistance
    • static = structural <== deposition of fibrous tissue + nodule formation
    • dynamic = vascular 
      • NO (vasodilator) decreased @ endothelium ==> further vasoconstriction
  • intrahepatic resistance ==> increased stress @ splachnic ==> increase NO ==> vasodilation ==> increased flow into portal system ==> further hypertension

5

Site of increased resistance in portal hypertension due to cirrhosis

sinusoidal

6

Hepatic Venous Pressure gradient in sinusoidal portal hypertension

  • Wedged hepatic venous pressure (WHVP) = elevated
  • Free HPV = normal
  • Gradient (HVPG) = elevated

7

Mechanism of varices formation

  • cirrhosis ==> portal hypertension ==> formation of portal-systemic collaterals
    • via dilation of coronary and gastric veins
    • collaterals = "gastroesophageal varices"
  • associations with variceal growth
    • Child B/C cirrhosis
    • alcoholic etiology
    • red wale marks on endoscopy

8

Characteristics of variceal hemorrhage

  • variceal size predicts variceal hemorrhage
  • rupture occurs when expanding force exceed max wall tension
  • ==> large or small bleeding ==> hematemesis

9

Tx for varices

  • vasoconstrictors e.g. octreotide
    • reduce splanchnic flow into liver ==> slight decrease in portal pressure
  • venodilators ==> intrahepatic venous dilation ==> slight decrease in portal pressure
  • vasoconstrictors + venodilators
  • endoscopic therapy (e.g. banding)
    • tx for varices ==> cauterized varice but no change in portal pressure
  • TIPS/shunt surgery
    • connect portion of portal vein ==> hepatic vein ==> sig. decrease in portal pressure
    • complications e.g. encephalopathy and liver failure

10

Mechanism of ascites formation in cirrhosis

  • elevated portal pressure ==> increased NO @ splachnic and systemic circulation
  • NO ==> 
    • splanchnic/systemic vasodilation
    • decreased effective arterial blood volume
    • activation of renin-angiotensin, aldosterone
    • sodium & water retention

11

Dx of ascites due to spontaneous bacterial peritonitis (SBP)

  • sx: fever, jaundice, abdominal pain
  • atypical presentation: only encephalopathy and/or renal dysfxn
  • diagnostic paracentesis shows:
    • PMN count > 250/mm3
    • positive culture

12

Dx of ascites due to cirrhosis

  • SAAG = serum-ascites albumin gradient
    • = serum albumin - ascitic fluid albumin
    • reflection of sinusiodal pressure
    • correflates w/HVPG
  • SAAG >= 1.1 g/dL ==> ascites due to sinusoidal hypertension
    • SAAG < 1.1 ==> source is likely peritoneal
  • total ascites protein < 2.5 g/dL
    • > 2.5 g/dl = heart fail

13

Mechanism of hepatic encephalopathy

  • HE = neuropsychiatric manifestations of cirrhosis of the liver
  • portosystemic shungtin + failure te metabolize neurotoxin substances ==> HE
  • ammonia ==> crosses BBB ==> up-regulation of astrocytic benzodiazepine (GABA) receptors ==> cortical depression/HE

14

Precipitating factors for HE

  • high protein load
  • GI bleeding
  • constipation
  • infection
  • over-diuresis ==> azotemia and hypokalemia
  • narcotics/sedatives can contribute
  • can occur in TIPS placement

15

Pre-hepatic causes of portal HTN

portal or splenic vein thrombosis

16

Pre-sinusoidal causes of portal HTN

schistosomiasis

17

Post-sinusoidal causes of portal HTN

veno-occlusive disease

18

Post-hepatic causes of portal HTN

Budd-Chiari syndrome (Hepatic Vein Thrombosis)

19

Characteristics of MELD score

  • = Model for End-Stage Liver Diseasescore.
  • estimate the 3-month mortality in patients with cirrhosis
  • used to rank patients on the liver transplant list.
  • It is derived from total bilirubin, creatinine, and INR (prothrombin time).