Flashcards in Cirrhosis Deck (32):
What is cirrhosis?
late stage of progressive hepatic fibrosis characterized by formation of regenerative nodules and irreversible at advanced stages
What are the complications of decompensated cirrhosis?
variceal hemorrhage, ascites, bacterial peritonitis, hepatic encephalopathy, hepatocellular carcinoma, hepatorenal syndrome, hepatopulmonary syndrome
What is portal hypertension?
an increase in the blood pressure within the portal venous system - veins coming from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver
What is ascites?
abnormal accumulation of fluid in the abdomen - assess for fluid wave with patient in the lateral decubitus position (tympany above fluid level) - treated with diuretics and sodium restriction
What are the symptoms of hepatic encephalopathy?
Stage 1: personality changes/vacant stare, insomnia/hypersomnia; Stage 2: lethargy, hand flapping (ataxia), tremor, hyperactive deep tendon reflexes; Stage 3: abusive, violent; Stage 4: coma
What is the pathogenesis of hepatic encephalopathy?
liver failure leads to inability to metabolize ammonia (NH3), which gets shunted to the brain causing toxicity
What are bleeding varices?
dilated blood vessels in the esophagus or stomach caused by portal hypertension - increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver) causes increased pressure within the veins - patients present with melena and/or hematemesis
What is hepatorenal syndrome?
development of renal failure in patients with advanced chronic liver disease - portal hypertension causes vasodilation which decreases vascular resistance and blood volume - leads to sodium and water retention, central hypovolemia, and impaired cardiac function
What are the common effects of portal hypertension?
esophageal varices (hematemesis/melena), spenomegaly, dilated abdominal veins (caput medusae), ascites, rectal varices (hemorrhoids)
What are the effects of cirrhosis?
coma, fetor hepatius (breath smells like a freshly opened corpse), spider nevi, gynecomastia, jaundice, ascites, loss of sexual hair, testicular atrophy, liver flap, bleeding tendency (decreased prothombin), anemia, ankle edema
What is hepatic hydrothorax?
presence of a pleural effusion (usually >500 mL) in a patient with cirrhosis who does not have other reasons to have a pleural effusion - chest tubes should NOT be placed - treated with diuretics and sodium restriction
How is hepatic hydrothorax treated?
furosemide (40 mg/day) and spironolactone (100 mg/day) with transjugular intrahepatic shunt, if necessary
What is hepatopulmonary syndrome?
shortness of breath and hypoxemia (low oxygen levels in the blood of the arteries) caused by vasodilation (broadening of the blood vessels) in the lungs of patients with liver disease
What is portopulmonary hypertension?
coexisting pulmonary arterial hypertension (PAH) and portal hypertension, when no alternative cause of the PAH exists - patient presents with fatigue, dyspnea, peripheral edema, chest pain, syncope
What is cirrhotic cardiomyopathy?
constellation of features (systolic and diastolic dysfunction, electrophysiological changes, and macroscopic and microscopic structural changes) indicative of abnormal heart structure and function in patients with cirrhosis
What is spontaneous bacterial peritonitis?
translocation of bacteria and endotoxins from GI tract to peritoneal fluid - complication of decompensated cirrhosis - polymorphonuclear leukocytes (granulocytes) > 250 cells/mm3 - seen in end stage liver disease - patient presents with fever, abdominal pain, abdominal tenderness, altered mental status
What is the empiric treatment for spontaneous bacterial peritonitis?
cefotaxime 2 g IV q8h
What are risk factors for decompensated cirrhosis?
bleeding, infection, alcohol intake, medications, dehydration, constipation - patients should be considered for liver transplant
What are the signs and symptoms of hepatocellular carcinoma?
pain, early satiety, obstructive jaundice, palpable mass, decompensation in a patient with previously compensated cirrhosis, rising alpha-fetoprotein levels in a patient with cirrhosis
What are ways to prevent superimposed insults to the liver?
vaccination against Hep A and B, avoid medications/substances associated with liver injury (alcohol, NSAIDs, herbal remedies)
Why are patients with cirrhosis prone to low platelet counts and elevated INRs?
liver makes coagulation factors and anticoagulant proteins - liver disease disrupts these processes
How are esophageal varices treated?
beta blockers or esophageal variceal ligation
What are measures to prevent complications with cirrhosis?
judicious diuresis, avoiding proton pump inhibitors, treat infections, avoid sedatives, treating hypokalemia and hyponatremia, avoid nephrotoxic agents, use urinary catheters/mechanical ventilation/central lines only when clearly needed
What is the Child-Pugh classification?
method of predicting prognosis in cirrhosis - includes serum albumin, bilirubin, ascites, encephalopathy, prothrombin time - scores range from 5 to 15 (5-6 well compensated, 7-9 functional compromise, 10-15 decompensated)
What is the MELD score?
method of predicting prognosis in cirrhosis - includes bilirubin, creatinine, INR, etiology of cirrhosis - MELD >= 10 should be referred for liver transplant
What are the common causes of cirrhosis in the U.S.?
chronic viral hepatitis, alcoholic liver disease, hemochromatosis, non-alcoholic fatty liver disease
What are the common presenting symptoms of compensated cirrhosis?
hepatomegaly (firm and nodular consistency), anorexia, weight loss, weakness, fatigue, muscle cramps, easy bruising, lower extremity edema, fever, diarrhea, confusion, sleep disturbance, chronic anovulation, hypogonadism (loss of male-pattern genital hair distribution)
What are common presenting symptoms of decompensated cirrhosis?
jaundice, "cola colored" urine, pruritis, upper GI bleeding, abdominal distension (ascites), confusion (hepatic encephalopathy), spider angiomata, gynecomastia, splenomegaly, palmar erythema (exaggerated speckled mottling of the palm), digital clubbing, asterixis, melena/hematochezia, fetor hepaticus (sweet, pungent smell of the breath)
What are some nail changes associated with cirrhosis?
Muehrcke nails (paired horizontal white bands separated by normal nail color) and Terry nails (proximal 2/3 of nail plate is white while distal 1/3 is red)
What is a Dupuytren's contracture?
fibroblastic proliferation and disorderly collagen deposition with fascial thickening - results from thickening and shortening of the palmar fascia (causes flexion deformities of the fingers)
What are common laboratory abnormalities in cirrhosis?
elevated ALT/AST (AST more common), elevated alkaline phosphatase, elevated gamma-glutamyl transpeptidase (GGT - more common with alcoholic cirrhosis), rising bilirubin, falling albumin, increasing prothombin time, hyponatremia, thrombocytopenia, anemia