Cirrhosis and Comp. of Liver D [3] Flashcards Preview

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Flashcards in Cirrhosis and Comp. of Liver D [3] Deck (26):
1

Complications of cirrhosis

variceal hemorrhage
ascites
encephalopathy
jaundice

2

Most common causes of cirrhosis

HCV
alcohol

3

Which one has complications?
Compensated cirrhosis
Decompensated cirrhosis

Compensated Cirrhosis - no complications
Decompensated cirrhosis - complications

4

Liver biopsy is not necessary to dx for pre-transplant eval if we can find what?

decompensated (complications) cirrhosis or CT scan diagnosing cirrhosis

PE: spider angiomata, palmar erythema

5

Mechanism of portal HTN and how it leads to cirrhosis

portal HTN can be due to increase resistance or increase in venous inflow

↑ intrahepatic resistance → portal HTN → distortion of sinusoidal architecture of the liver → even more ↑ R

(blood has to go through different ways like esophagus to get back to heart; also blood backs up in portal veins leading to splenomegaly)
- ↑ intrahepatic resistance in cirrhosis is not only structural but also fxnal

6

MELD score

estimates risk of 3 mo mortality
Determines priority in cirrhosis
- higher score = priority

6.4+9.8xlog(INR) + 11.2xlog(Cr) + 3.8xlog(Bili)

nL = 6

7

Cirrhosis is what type of portal HTN

Sinusoidal
- small hepatic v are obstructed
- RUQ pain, ascites, hepatomegaly, jaundice

HVPG is increased >5

8

Pre-hepatic HTN

Portal or splenic ven thrombosis
liver is nl, blood backs up in spleen and esophagus

9

Pre-sinusoidal portal HTN

Shistosomiasis
- eggs are stuck b4 the sinusoids

HVPG is nl (3-5)

10

Post-sinusoidal portal HTN

veno-occlusive disease

HVPG is increased >5

11

Post-hepatic portal HTN

Budd-chiari syndrome
(hepatic vein thrombosis)

HVPG is nl (↑P - ↑P @ heart)
(pre and post hepatic is nl)

12

In cirrhosis, NO activity is ____ and vasoconstrictors are ____

NO reduced
VC increased

→ increased resistance →
- structural changes (fibrosis, regenerative nodules)
- active vasoconstriction (↓No, ↑VC)

(note: ↑ NO → splanchnic vasodilation → ↑portal venous inflow → ↑portal HTN)

13

NL hepatic venous pressure gradient (HVPG) is

3-5 mmhg

HVPG = WHVP - FHVP

14

Which type of portal HTN is HVPG elevated in?

sinusoidal
post sinusoidal

15

Predictors of variceal hemorrhage

variceal size (larger more likely to rupture)
red signs (risk 4 bleed)
child

16

Decreasing what two things reduce risk of variceal rupture?

↓ portal P
↓ HVPG

17

Therapies for varices

Vasoconstrictor - OCTREOTIDE!
- ↓ splanchnic flow → ↓portal pressure

TIPS/shunt surgery
- create comm btwn portal v and hepatic V

18

Most common cause of ascites

cirrhosis
- US is most sensitive way to detect ascites

19

How does portal HTN result in ascites?

Portal HTN → shear stress → ↑ NO → vasodilation → BP goes down → activation of neurohormonal systems (renin, angiotensin, aldosterone) → sodium and water retension → ASCITES

20

Refractory ascites

acites that cannot be managed by diuretics anymore
-80%

21

Serum-Ascites Albumin Gradient (SAAG):

. SAAG correlates with sinusoidal pressure. SAAG 1.1 nl

Most patients with CIRRHOTIC ASCITES will have serum-ascites albumin GREATER than 1.1

Peritoneal malignancy will be less than 1.1

22

Hepatorenal syndrome
- what is always present?

renal failure in pts with:
1. cirrhosis
2. advanced liver failure
3. severe sinusoidal portal HTN

ASCITES AND HYPONATREMIA are ALWAYS PRESENT IN HRS

- no significant change in kidney
(fxnl renal failure)

23

Type I vs Type II hepatorenal syndrome

Type I: rapidly progressive renal failure (2 weeks)
Type II: more slowly progressive

24

Spontaneous Bacterial Peritonitis (SBS)

bacterial translocation →
migration of viable microorganisms from intestinal lumen to mesenteric lymph nodes and other extraintestinal organs and sites →
increase conditions associated with high risk of infxn by gram (-) organisms (burn, shock, trauma) but DOES NOT increase pre-hepatic portal HTN

25

Hepatic Encephalopathy

neuropsychiatric complication due to
1. portosystemic shunt
2. chronic liver failure

Due to failure to metabolize neurotoxic substances (hyperammonemia) → glutamine accumulation

(note: astrocytes are the only cells in the brain that can metabolize ammonia)

26

tx for hepatic encephalopathy

lactulose
- 2-3 bowel movements/day
- less time to absorb ammonia, trap it in colon and increase movement through colon

Antibiotics to kill bacteria in gut that make ammonia