Cirrhosis -Jenkins

Question 1

What is cirrhosis? What does this lead to?

Answer 1

• histologically=diffuse fibrosis and the conversion of normal liver architecture into structurally abnormal nodules
• fibrosis: activation of hepatic stellate cells–> formation of inc amounts ofcollagenand other components of the extracellular matrix

–> dec in hepatocellular mass and function and alteration in blood flow

Question 2

What does cirrhosis of the liver look like on ultrasound?

Answer 2

-ascities with a small nodular liver

Question 3

Can cirrhosis be reversible?

Answer 3

In early stages, especially if it is due to HCV, it can be responsive to treatment

advanced stages =liver transplant

Question 4

***What is the most common cause of cirrhosis in the United States?

Answer 4

Fatty liver d/t: #1 Hep C, #2 Alcoholic liver disease

Question 5

What labs can be used for prognosis of end stage liver disease?

Answer 5

• cholesterol ( inc INR)

- albumin (low is poor prognosis because made in liver)

Question 6

***What can the AST and ALT be in cirrhosis? What do these labs indicate?

Answer 6

in cirrhosis, can be normal

indicate inflammation
highest AST and ALT in alcoholic hepatitis or NASH

Question 7

What will cause a super elevated ALP?

Answer 7

biliary disease

Question 8

What will bilirubin levels be in cirrhosis?

Answer 8

normal in well-compensated cirrhosis but will rise as cirrhosis progresses

Question 9

***TRUE OR FALSE: Hepatitis B is the most common case of cirrhosis

Answer 9

FALSE (Hep C is, along with alcohol and fatty liver)

Question 10

What are some complications of cirrhosis?

Answer 10

• portal HTN –> hemorrhoids, esophageal varices, ascites, hypersplenism
• ascites: excess fluid (lymph) in the peritoneal cavity
• hepatorenal syndrome (renal vasoconstriction)
• hepatopulmonary syndrome
• hepatic encephalopathy
• hyponatremia
• malnutrition
• osteoporosis
• hypogonadism
• fetor hepaticus (sweet, pungent breath)
• Dupuytren’s contracture

Question 11

What are the most common treatments for acute variceal bleeds? What procedure can be done to prevent re-bleeds?

Answer 11

band ligation and octreotide (a splanchnic vasoconstrictor)

TIPS to prevent re-bleeds if other tx fails

Question 12

What is an important complication of TIPS?

Answer 12

a stent is placed to release portal HTN into the vena cava==> bypass the liver

–> risk of toxins (ammonia) is higher –> greater risk of hepatic encephalopathy

Question 13

***What is the pathophysiology of ascites due to cirrhosis?

Answer 13

-vasodilation of the splanchnic system leads to dec filling in systemic system–> inc RAAS –> inc Na+ and H2O retention)
-hypoalbuminemia also causes a dec plasma oncotic P –> more leaking fluid into the peritoneal cavity –> more peripheral edema
(*Sum: increased portal pressure and low albumin)

Question 14

What other complications can result from ascites?

Answer 14

• resp function can be compromised –> SOB
• malnourished
• mm wasting
• anorexia
• fatigue
• abd discomfort and pressure
• gynecomastia
• Spontaneous bacterial peritonitis
• hydrothorax (pleural effusion)

Question 15

How can you determine if someone has ascites or is just fat?

Answer 15

• shifting dullness in percussion when pt is supine vs on side
• fluid wave (non-specific)
• US (can detect as little as 30 mL of fluid)

Question 16

What is the treatment for severe ascites?

Answer 16

Paracentesis : needle into the peritoneal cavity to drain the ascitic fluid (also used for dx)

also, *diuretics (spironolactone) and sodium restriction

-should also be done when present with ascites for the 1st time to diagnose the fluid

Question 17

***What is the #2 cause of ascites?

Answer 17

cancer (ovary and liver)

cirrhosis is #1

Question 18

What are the most typical symptoms of spontaneous bacterial peritonitis? What should be the suspected cause if 2+ organisms are found in the ascitic fluid?

Answer 18

fever and abd pain

2+ organisms==> suspect a perforated viscus

Question 19

What is the 1 year survival rate of someone with massive ascites?

Answer 19

< 50%

liver transplant needed

Question 20

How does INR correspond to prognosis of cirrhosis? Why?

Answer 20

higher INR==> worse prognosis

clotting factors are created by the liver.

Vitamin K requires biliary excretion for its absorption. liver failure–> Less vitamin K –> dec 2, 7, 9, and 10 clotting factors

Question 21

What can hypersplenism lead to? What physical finding can be seen?

Answer 21

thrombocytopenia (sequestration of platelets–> low platelets)

petichiae

can also lead to DIC

Question 22

***What is pancytopenia? What is the most common cause of this?

Answer 22

pancytopenia=thrombocytopenia (low platelets), leukopenia (low WBC) and anemia (low hemoglobin)

cirrhosis (hypersplenism)

Question 23

What is the #1 cause of anemia in cirrhosis?

Answer 23

hypersplenism

Question 24

What is the reason hyponatremia is common in pts with cirrhosis and ascites?

Answer 24

inability to excrete free water because of high levels of ADH (activated by systemic vasodilation)

–> low sodium

Question 25

What is the best therapy for hepatorenal syndrome?

Answer 25

liver transplant

Question 26

What is hepatopulmonary syndrome? Is this the same as hepatic hydrothorax?

Answer 26

Triad of: - Liver disease - Increased alveolar-arterial gradient while breathing room air - Evidence of intrapulmonary vascular dilatations  NOT THE SAME!

Question 27

***What are the 2 main causes of death due to cirrhosis?

Answer 27

hepatic encephalopathy and GI bleeding

Question 28

***What is asterixis? Which pts will present with this?

Answer 28

bilateral but asynchronous flapping motions of outstretched dorsiflexed hands seen in pts with hepatic encephalopathy

Question 29

What medications are used to treat hepatic encephalopathy? (3)

Answer 29

- LACTULOSE (first line) (stimulates ammonia passage from tissues to gut lumen and inhibits ammonia production) - Neomycin (antibiotic) - other antibiotics (3 meds==> ALL oral. if pt is comatose--> NG tube)

Question 30

What is the difference between compensated and decompensated cirrhosis? What is the median survival with both?

Answer 30

(Important for transplants) - compensated=no major complications - -> median survival is 12 years - decompensated=have complications (i.e. variceal bleeding, SBP, hepatocellular carcinoma, etc) - -> median survival is < 6 months

Question 31

What is Dupuytren's contracture? What type of cirrhosis is this commonly seen in?

Answer 31

- results from thickening and shortening of the palmar fascia --> flexion deformities of the fingers * common in alcoholic cirrhosis

Question 32

What are some other PE findings in cirrhosis?

Answer 32

- Jaundice - scleral icterus - palmar erythema - Muehrcke's nails (transverse white bands in the nails that do not indent) - Terry's nails (proximal 2/3 of the nail bed is white and distal 1/3 is red) - clubbing - spider angiomata (spider telangiectasis)

Question 33

***What is the treatment for cirrhosis?

Answer 33

* Intravascular volume is low so aldosterone level would be very high → retain sodium and water: 1. Fluid restriction (makes aldosterone higher though) 2. Na restriction (lowers intravascular volume → raises aldosterone) 3. Lasix (lowers intravascular volume → raises aldosterone) 4. Spironolactone (given to every patient b/c anti-aldosterone) * TIPS – decreases ascites and varices * La Veen shunt * Liver transplant – ultimate treatment