Cirrhosis, Portal HTN, etc. Flashcards Preview

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Flashcards in Cirrhosis, Portal HTN, etc. Deck (37):
1

Patho cirrhosis

- end result of hepatocellular injury-->slow fibrosis and nodular regeneration throughout the liver
- hepatocyte injury due to cytokine release and inflammatory response--> hepatocyte/bile duct cell/ vascular endothelial cell death

2

Is cirrhosis reversible?

No, only the initial fibrosis is via removal

3

Complications of cirrhosis

ascites
portal htn
hepatorenal syndrome
hepatic encephalopathy
spontaneous bacterial peritonitis
coagulopathy
GI varices

4

Cause cirrhosis

hepatitis c
alcoholic liver disease
hep c + alcoholic liver disease
Non-alcoholic fatty liver dz (obesity, DM, hyperTG)
Hep B
hemochromatosis
wilson dz
alpha 1 antitrypsin deficiency

5

Clinical Cirrhosis

- asymptomatic till late stage
- fatigue
- sleep disturbance
- muscle cramps
- weight loss/wasting
-spider telangiectasias on face
- abdominal and thoracic superficial veins are dilated
- palmar erythema
- peripheral edema
- splenomegaly
- liver enlargement; palpable and firm
- ascites
- hematemesis
- icteric sclera
- pruritis with no rash
- encephalopathy (confusion/altered mental status)

6

Labs cirrhosis

macrocytic anemia due to ETOH suppression of EPO
low WBC
Thrombocytopenia

7

Imaging cirrhosis

US/CT- nodular liver

8

The imperfect gold standard for cirrhosis

liver biopsy

9

Fibrosure test

- biomarker test that uses the results of 6 serum tests to generate a score which is equivalent to the predictive value of liver biopsy
- replaces liver biopsy

10

Transient elastography

- used at the bedside, non-invasive test
- ultrasound passes a vibratory wave through the liver and measure hepatic fibrosis/liver stiffness
- limitations ascites, chest wall fat, obesity, and severe liver inflammation

11

MELD score

- prognostic scoring system for cirrhosis
- measure mortality risk and predict short and intermediate survival and complication of cirrhosis
- how bad is my disease and where am I on the transplant list

12

MELD score includes what

total bilirubin
age
sodium
INR
creatinine

13

Scores of MELD score

6= 90 mortality of 40%
16-20= 90 mortality of 56%
more than 26= 90 mortality of 85%

14

Patho portal HTN

- increased hydrostatic pressure within the portal vein; more than 10-12mmhg --> collaterals develop
- progressive increase in peripheral resistance to portal venous flow
- as mmhg increases blood flow decreases and then mmhg is transferred to portal vein tributaries with subsequent dilation --> collateral formation

15

Sequelae of portal HTN

ascites
esophageal and gastric varices
splenomegaly and thrombocytopenia

16

Prophylactic tx for portal HTN

non-selective beta blocker (nadolol)

17

Cause portal HTN

portal/splenic vein thrombosis
cirrhosis(mc)
acute hepatitis
schistosomiasis
budd-chiari
R. HF

18

Patho Ascites

pathologic accumulation of excess fluid in the peritoneal cavity

19

Causes of ascites

cirrhosis
neoplasms
CHF

20

Clinical ascites

- abdominal distention
- bulging flanks
- shifting dullness to percussion
- fluid wave
**need 1500ml of fluid to see this

21

Dx ascites

US
paracentesis

22

Tx ascites

Na+ (<1.5g) and water restriction (<1.5L)- first line
Diuretic- 2nd line (spironolactone and furosemide): make sure not water restricted--> dehydration
Surgery
- large volume paracentesis (5-7L)
- Transjugular inrahepatic portosystemic shunt (TIPS)- need MELD<18 and total bilirubin <3 --> serious complications
- liver transplant

23

What is hepatic encephalopathy

late cirrhosis induced mental status change
- personality change
- intellectual impairment
- depressed level of consciousness

24

Patho hepatic encephalopathy

bacteria in gut produces ammonia and the liver usually detoxifies it but due to cirrhosis the liver cannot detoxify the ammonia--> accumulation
GABA increase neurotransmitter inhibition--> ammonia accumulation

25

Clinical hepatic encephalopathy

- cirrhosis
- asterixis
- twitchiness
- minor impairment of memory, coordination and cognition

26

Lab and EEG hepatic encephalopathy

- Ammonia elevation
- EEG: high amplitude low frequency waves and triphasic waves

27

Cause of hepatic encephalopathy

anything that causes dehydration
- infection
- diuretic
- hypovolemia
- renal failure
- Constipation

28

Tx hepatic encephalopathy

PO, NGT
lactulose titrated to number of bowel movements per day
ABX- xifaxan

29

Varices

dilated veins

30

Where do varices form

junction of portal and systemic venous system

31

Where are GI collaterals/varices

distal esophagus and proximal stomach

32

What causes varices

- increased portal vein pressure
- diversion of blood back to systemic veins due to high mmhg through liver thus forming collaterals between IVC and SVC and portal venous system

33

What do varices cause

severe bleeding directly related to portal pressure

34

Risk of bleed with varicies

anything that causes portal HTN
alcohol
large varices
red marks on varices- red whale sign
severe cirrhosis and liver failure

35

Clinical varicies

- hematemesis
-melena
- hematochezia
- pale
- hypotensive
- lightheaded
- syncope
- orthostatic
- tachycardia
- hemorrhagic shock
-liver disease/cirrhosis

36

Tx varicies

- 2 large bore IVs
- pRBC Hgb<7
- NGT with lavage
- Octreotide 50mcg/hr- splanchnic vasoconstriction
- balloon tube tamponade- temporary measure to stop bleed
- endoscopy- definitive tx
- TIPS
- algotherapy

37

Prevent rebleed of varices

- Nadolol titrated to max
- endoscopic band ligation: strangles varix