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Flashcards in End Stage Liver Disease Deck (33):
1

What are the two types of damage seen in decompensated cirrhosis?

hepatocellular dysfunction
complications of portal hypertension

2

List clinical signs of hepatocellular dysfunction

Jaundice, cholestasis
fat soluble vitamin deficiency
coagulopathy- bleeding and bruising
hepatic encephalopathy
hypoalbuminemia
hormonal deficiencies

3

List complications of portal hypertension

Ascites
Spontaneous Bacterial Peritonitis
Hepatorenal Syndrome
Variceal Hemorrhage
Hepatic Encephalopathy
Pulmonary Complications of Cirrhosis

4

List pre hepatic causes of portal hypertension

portal vein thrombosis

5

List post hepatic causes of portal hypertension

IVC or hepatic vein occlusion

6

List intrahepatic portal hypertension

- post sinusoidal
- sinusoidal (cirrhosis)
- pre sinusoidal (schistosomiasis)

7

In patients with cirrhosis, portal hypertension leads to shunting and increased capillary hydrostatic pressure, with ______ fluid shift into the peritoneal cavity

transudative

8

The combination of shunting and hepatocellular dysfunction in cirrhosis leads to decreased clearance of endogenous vasodilators such as ______

nitric oxide

9

Splanchnic ______ leads to increased portal inflow, further worsening portal hypertension

vasodilation

10

Splanchnic vasodilation leads to a decrease in the_______, with subsequent reduction in vascular tone and blood pressure causing activation of the RAAS and SNS systems

effective circulating volume (ECV)

11

Activation of RAAS and SNS, total body fluid increases, and portal hypertension eventually overwhelm the lymphatics of the liver and splanchnic system, leading to ______ formation

ascites

12

________ leads to the complication of hepatorenal syndrome

Renal vasoconstriction (in response to perceived low circulating volume)

13

What is the SAAG?

Serum to ascites albumin gradient
= serum albumin- ascites albumin
if > 1.1 then ascites is due to portal hypertension
if < 1.1 then ascites is due to malignancy, TB, bile leak, SLE, etc

14

__________ can be caused by intense renal vasoconstriction in the setting of portal hypertension

acute kidney injury

15

List common precipitants of hepatorenal syndrome

infection esp spontaneous bacterial peritonitis
diuretics
paracentesis
lactulos

16

How can hepatorenal syndrome be distinguished from pre-renal failure

Unlike pre-renal failure, HRS does not respond to volume expansion

17

Describe the formation of varices in portal hypertension

Collateral vessels from, when portal pressure increases, these collaterals dilate and are called varices.

18

Describe the pathophysiology of hepatic encephalopathy

- decreased hepatocellular function- unable to eliminate toxins that cause hepatic encephalopathy
- shunt: portal blood is shunted away from the liver, so liver is not able to detoxify substances
- ammonia and other toxins disturbe neurotransmission and lead to osmotic swelling of astrocytes

19

Splenomegaly leads to ______, which causes consumption and sequestration, initially of platelets leading to thrombocytopenia

hypersplenism

20

List endocrine features of hepatocellular insufficiency

- androgenic failure and feminization
- amenorrhoea, anovulation
- spider angiomata
- palmar erythema

21

Describe the pathology of bone disease in chronic liver disease

immobility and lack of sunlight
disordered hepatic metabolism of vitamin D

22

List infections that people with cirrhosis are at risk for

pneumonia
sepsis secondary to UTI
TB
SBP

23

_______ is a bacterial infection of ascites fluid in a patient with liver disease

spontaneous bacterial peritonitis

24

How is SBP diagnosed?

> 250 PMNs per ml ascitic fluid

25

What malignancies are more common in people with cirrhosis

HCC
hepatoma
cholangiocarcinoma

26

What are causes of death for people with end stage liver disease?

Acute gastrointestinal hemorrhage
Bacterial infection
Multisystem failure, particularly the combination of hepatic and renal failure

27

Describe therapy for acute variceal bleeding

resuscitation- RBCs, FFP
vasoactive medications- octreonide causes splanchnic vasoconstriction and reduces portal flow
antibiotics
PPIs
emergency endoscopy- band ligation or sclerosants if band ligation is not possible

28

_______ causes splanchnic vasoconstriction and reduces portal blood flow

octreonide

29

For patients that fail endoscopic control of variceal hemorrhage_________ can be placed

portosystemic shunts
ex TIPS procedure

30

What are measures used to reduce the risk of rebleeding in patients treated for variceal hemorrhage?

beta blockers- induce splanchnic vasoconstriction
TIPS if refractory bleeding

31

What measures are used to treat hepatorenal syndrome, ascites, and SBP

low salt diet
diuretics esp loop and spironolactone
paracentesis + albumin
TIPS
IV antibiotics + albumin

32

Giving IV albumin along with antibiotics in SBP can reduce mortality and the risk of developing _________

hepatorenal syndrome

33

How is hepatic encephalopathy treated?

avoid or remove precipitants- diuretics, benzos, opioids
lactulose - traps NH3 in form of NH4
rifaximin