Cirrhosis

Question 1

What is cirrhosis?

Answer 1

late stage of progressive hepatic fibrosis characterized by formation of regenerative nodules and irreversible at advanced stages

Question 2

What are the complications of decompensated cirrhosis?

Answer 2

variceal hemorrhage, ascites, bacterial peritonitis, hepatic encephalopathy, hepatocellular carcinoma, hepatorenal syndrome, hepatopulmonary syndrome

Question 3

What is portal hypertension?

Answer 3

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

Question 4

What is ascites?

Answer 4

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

Question 5

What are the symptoms of hepatic encephalopathy?

Answer 5

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

Question 6

What is the pathogenesis of hepatic encephalopathy?

Answer 6

liver failure leads to inability to metabolize ammonia (NH3), which gets shunted to the brain causing toxicity

Question 7

What are bleeding varices?

Answer 7

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

Question 8

What is hepatorenal syndrome?

Answer 8

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

Question 9

What are the common effects of portal hypertension?

Answer 9

esophageal varices (hematemesis/melena), spenomegaly, dilated abdominal veins (caput medusae), ascites, rectal varices (hemorrhoids)

Question 10

What are the effects of cirrhosis?

Answer 10

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

Question 11

What is hepatic hydrothorax?

Answer 11

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

Question 12

How is hepatic hydrothorax treated?

Answer 12

furosemide (40 mg/day) and spironolactone (100 mg/day) with transjugular intrahepatic shunt, if necessary

Question 13

What is hepatopulmonary syndrome?

Answer 13

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

Question 14

What is portopulmonary hypertension?

Answer 14

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

Question 15

What is cirrhotic cardiomyopathy?

Answer 15

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

Question 16

What is spontaneous bacterial peritonitis?

Answer 16

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

Question 17

What is the empiric treatment for spontaneous bacterial peritonitis?

Answer 17

cefotaxime 2 g IV q8h

Question 18

What are risk factors for decompensated cirrhosis?

Answer 18

bleeding, infection, alcohol intake, medications, dehydration, constipation - patients should be considered for liver transplant

Question 19

What are the signs and symptoms of hepatocellular carcinoma?

Answer 19

pain, early satiety, obstructive jaundice, palpable mass, decompensation in a patient with previously compensated cirrhosis, rising alpha-fetoprotein levels in a patient with cirrhosis

Question 20

What are ways to prevent superimposed insults to the liver?

Answer 20

vaccination against Hep A and B, avoid medications/substances associated with liver injury (alcohol, NSAIDs, herbal remedies)

Question 21

Why are patients with cirrhosis prone to low platelet counts and elevated INRs?

Answer 21

liver makes coagulation factors and anticoagulant proteins - liver disease disrupts these processes

Question 22

How are esophageal varices treated?

Answer 22

beta blockers or esophageal variceal ligation

Question 23

What are measures to prevent complications with cirrhosis?

Answer 23

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

Question 24

What is the Child-Pugh classification?

Answer 24

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)

Question 25

What is the MELD score?

Answer 25

method of predicting prognosis in cirrhosis - includes bilirubin, creatinine, INR, etiology of cirrhosis - MELD >= 10 should be referred for liver transplant

Question 26

What are the common causes of cirrhosis in the U.S.?

Answer 26

chronic viral hepatitis, alcoholic liver disease, hemochromatosis, non-alcoholic fatty liver disease

Question 27

What are the common presenting symptoms of compensated cirrhosis?

Answer 27

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)

Question 28

What are common presenting symptoms of decompensated cirrhosis?

Answer 28

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)

Question 29

What are some nail changes associated with cirrhosis?

Answer 29

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)

Question 30

What is a Dupuytren’s contracture?

Answer 30

fibroblastic proliferation and disorderly collagen deposition with fascial thickening - results from thickening and shortening of the palmar fascia (causes flexion deformities of the fingers)

Question 31

What are common laboratory abnormalities in cirrhosis?

Answer 31

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

Question 32

What are the factors that best predict cirrhosis?

Answer 32

ascities, platelet count < 160,000/mm3, spider angiomata, ALT/AST ratio < 0.6, INR > 1.4