Liver Distension

Question 1

What is the normal portal vein pressure?

Answer 1

5mmHg

Question 1

What are the most common causes of upper GI bleeds?

Answer 1

Peptic ulcer disease

Varices

Esophagitis

Mallory-Weiss tear (oesophageal tear, usually from vomiting due to alcohol)

Other: cancer, angiodysplasia (usually smaller volumes)

Question 2

What must be done before endoscoping variceal bleeds?

Answer 2

Fluid resus - don’t give too much blood though as it will exacerbate the hypertension

Splanchnic vasoconstrictor to reduce portal pressure - Terlipressin or octreotide

Question 3

What do platelets reflect in terms of hepatic function?

Answer 3

Portal hypertension

Not synthetic function of the liver

Question 4

What are the most common causes of cirrhosis?

Answer 4

Alcohol

Hep C

NASH

Hep B

Question 5

How do you management ascites?

Answer 5

Sodium restriction

Fluid restriction

Diuretics

Therapeutic ascitic tap

Question 7

What are the 6 F’s of abdominal distension?

Answer 7

Fat

Fluid

Foetus

Faeces

Flatus

Fucking big tumour

Question 7

What are the 5 criteria for Child-Pugh scoring?

Answer 7

Ascites

Bilirubin

Albumin

INR

Encephalopathy

Question 8

When do you screen for varices?

Answer 8

Any new diagnosis of cirrhosis in the presence or absence of portal hypertension

Question 8

What are alternatives to variceal banding?

Answer 8

Endoscopic - Sclerosant or glue

• Tamponade - Senstaken tube

Medical - Splanchnic vasocontrictor - tellipressin

Surgical - Portal-systemic shunt

Radiological - Shunt or occlusion

Question 9

What medications do you give in the acute setting post variceal bleeds?

Answer 9

Continue terlipressin

Empiric IV antibiotics

Question 10

Why might you get hyponaturaemia in portal hypertension?

Answer 10

Portal hypertension stimulations increase in blood volume via ADH and renin angiotension system which causes water retention

Question 10

How do you confirm Hep C diagnosis?

Answer 10

PCR - shows active infection

Question 11

What is SBP?

Answer 11

Spontaneous bacterial peritonitis

Common complication of cirrhosis due to leaky membrane, poor opsonisation and suboptimal immune response

Question 12

What can US show in portal hypertension?

Answer 12

Ascites

Nodular liver

Rencanalisation of ligamentum teres with reversal of flow in portal vein

Screen for space occupying lesions

Hepatic vein - ?Budd Chiari

Question 13

What prophylaxis is there for varices?

Answer 13

Non-selective beta-blockers - Propranolol

Banding

Question 14

Why do platelets drop in portal hypertension?

Answer 14

They are sequested in the spleen

Question 15

What drugs is available for Hep C?

Answer 15

Sobosbuvir

Question 16

What percentage of Hep C patients get cirrhosis?

Question 18

How do you differentiate a transudate from an exudate on ascitic fluid?

Answer 18

SAAG = serum albumin - ascites albumin (>11g/L = portal hypertension fluid)

Exudate = >25g/L in ascitic fluid

Question 21

How do you diagnosis SBP?

Answer 21

>250 polymorphs in ascitic tap

Question 23

How does the portal vein system compensate for increased pressure? What are the implications of that?

Answer 23

Creation of collaterals eg caput medusae - these can divert up to 90% of flow but to heart

They are also the vessels that bleed

Question 23

At what portal pressure do varices form?

Answer 23

10mmHg

Bleed at 12mmHg

Question 24

What are the greatest risk factors for Hep C infection?

Answer 24

IVDU

Tattoo’s overseas

Question 25

What is considered significant alcohol comsumption?

Answer 25

At least \>30g (ie 3 units) daily for \>5 years

Question 26

What are the most common causes of ascites?

Answer 26

Cirrhosis Alcoholic hepatitis Cardiac failure or pericarditis Budd-Chiari syndrome Massive hepatic metastasis

Question 27

What is the pathophysiology of portal hypertension?

Answer 27

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

Question 28

Which diuretic is best for ascites?

Answer 28

Spironolactone starting at 50mg/daily (titrate to 400mg/d) - watch for gynacomastica Add frusemide (initially 40/mg/d)

Question 29

What are some causes of ascites in which portal hypertension is not a feature?

Answer 29

Peritoneum carcinomatosis Nephrotic syndrome Pancreatitis Perineal TB Serositis

Question 30

How do you replace albumin when performing a ascitic tap?

Answer 30

200ml of 20% conc albumin for every 2L removed

Question 32

What are varices?

Answer 32

Engorged collateral vessels and porto-systemic shunting due to portal hypertension

Question 33

What is the MELD score? What is it used for? How is it determined?

Answer 33

Model of End-stage Liver Disease Used for liver transplant waiting lists INR, Bilirubin and Cr