What is the normal portal vein pressure?
What are the most common causes of upper GI bleeds?
Peptic ulcer disease
Mallory-Weiss tear (oesophageal tear, usually from vomiting due to alcohol)
Other: cancer, angiodysplasia (usually smaller volumes)
What must be done before endoscoping variceal bleeds?
Fluid resus - don't give too much blood though as it will exacerbate the hypertension
Splanchnic vasoconstrictor to reduce portal pressure - Terlipressin or octreotide
What do platelets reflect in terms of hepatic function?
Not synthetic function of the liver
What are the most common causes of cirrhosis?
How do you management ascites?
Therapeutic ascitic tap
What are the 6 F's of abdominal distension?
Fucking big tumour
What are the 5 criteria for Child-Pugh scoring?
When do you screen for varices?
Any new diagnosis of cirrhosis in the presence or absence of portal hypertension
What are alternatives to variceal banding?
Endoscopic - Sclerosant or glue
- Tamponade - Senstaken tube
Medical - Splanchnic vasocontrictor - tellipressin
Surgical - Portal-systemic shunt
Radiological - Shunt or occlusion
What medications do you give in the acute setting post variceal bleeds?
Empiric IV antibiotics
Why might you get hyponaturaemia in portal hypertension?
Portal hypertension stimulations increase in blood volume via ADH and renin angiotension system which causes water retention
How do you confirm Hep C diagnosis?
PCR - shows active infection
What is SBP?
Spontaneous bacterial peritonitis
Common complication of cirrhosis due to leaky membrane, poor opsonisation and suboptimal immune response
What can US show in portal hypertension?
Rencanalisation of ligamentum teres with reversal of flow in portal vein
Screen for space occupying lesions
Hepatic vein - ?Budd Chiari
What prophylaxis is there for varices?
Non-selective beta-blockers - Propranolol
Why do platelets drop in portal hypertension?
They are sequested in the spleen
What drugs is available for Hep C?
What percentage of Hep C patients get cirrhosis?
How do you differentiate a transudate from an exudate on ascitic fluid?
SAAG = serum albumin - ascites albumin (>11g/L = portal hypertension fluid)
Exudate = >25g/L in ascitic fluid
How do you diagnosis SBP?
>250 polymorphs in ascitic tap
How does the portal vein system compensate for increased pressure? What are the implications of that?
Creation of collaterals eg caput medusae - these can divert up to 90% of flow but to heart
They are also the vessels that bleed
At what portal pressure do varices form?
Bleed at 12mmHg
What are the greatest risk factors for Hep C infection?
What is considered significant alcohol comsumption?
At least >30g (ie 3 units) daily for >5 years
What are the most common causes of ascites?
Cardiac failure or pericarditis
Massive hepatic metastasis
What is the pathophysiology of portal hypertension?
Fixed and dynamic structural changes occur in the liver > pressure in the portal vein increase > transferred to the splanic circulation > NO production > Vasodilation > Stimulates global increase blood volume > further exacerbates hypertension
Which diuretic is best for ascites?
Spironolactone starting at 50mg/daily (titrate to 400mg/d)
- watch for gynacomastica
Add frusemide (initially 40/mg/d)
What are some causes of ascites in which portal hypertension is not a feature?
How do you replace albumin when performing a ascitic tap?
200ml of 20% conc albumin for every 2L removed
What are varices?
Engorged collateral vessels and porto-systemic shunting due to portal hypertension
What is the MELD score? What is it used for? How is it determined?
Model of End-stage Liver Disease
Used for liver transplant waiting lists
INR, Bilirubin and Cr