117b Complications of cirrhosis

Question 1

complications of cirrhosis

Answer 1

ascites and hepatic hydrothorax (through diaphragm via holes)
HPS and HRS
Varices --> bleeding
encephalopathy (ammonia)
HCC

Question 2

where does cirrhosis damage occur in the liver that leads to portal HTN? What else contributes to ascites?

Answer 2

scarring in sinusoids –> portal HTN

arterial splanchnic vasodilation leads to blood pooling

Question 3

stellate cells - location and role in cirrhosis

Answer 3

space of disse

lay down collagen from hepatic injury –> fibrosis –> cirrhosis

Question 4

ascites development - pathogenesis and timeline of fluid build up

Answer 4

portal HTN –>
systemic + splanchnic vasodilation via NO –>
lowers renal perfusion –> increased RAAS, SNS, ADH –> retain salt and water –> fluid oozes from abdominal organs

fluid build up quickly

Question 5

ascites and hepatic hydrothorax - what labs confirm that its from portal HTN?

Answer 5

• high SAAG (serum ascites albumin gradient) = serum albumin - ascites albumin
• lower protein (<2.5)

Question 6

Ascites and Hepatic Hydrothorax - treatment + what should never be used?

Answer 6

1) salt < 2 g/day (usually not fluid restriction unless hyponatremic in late stages)
2) diuretics - lasix (furosemide) and aldactone (spironolactone)
3) paracentesis as needed
4) prophylaxis against SBP (spont bact peritonitis) in some patients
5) Use TIPS.

Never put in a chest tube OR drainage catheter in abdomen – high risk of infection without benefit

Question 7

when should prophylaxis for SBP be considered?

Answer 7

GI bleeds
Hostpialized patient (protein <1.5)

Question 8

TIPS and what it does

Answer 8

Transjugular intrahepatic portosystemic shunt

bypasses liver sinusoids - reduces ascites by reducing portal HTN

Question 9

hepatopulmonary syndrome - what happens in the lungs? what does this lead to?

Answer 9

intrapulmonary vascular dilations (IPVD) from NO at base of lung –> hypoxia due to ventilation/perfusion mismatch

Question 10

HPS patient symptoms/findings and treatment

Answer 10

1) spider angiomata
2) orthodeoxia playpnea - sit up and get short of breath and deoxygenated
treatment - supplemental O2 and transplant (curative)

Question 11

hepatorenal syndrome - pathogenesis and outcomes

Answer 11

cirrhosis –> portal HTN –> splanchnic and systemic vasodilation –> low effective circulating volume –> heart pumps harder (high output heart failure) + increased Na/water retention + kidney vasoconstriction

reversible
high risk of death

Question 12

HRS treatment

Answer 12

1) hold diuretics
2) volume replacement with albumin -> increases kidney perfusion
3) if 48 hrs w/out improvement -> use cocktail
albumin
octreotide (reduces splanchnic vasodilation)
midodrine (a-agonist - systemic vasoconstrictor)

Question 13

portal HTN - varices locations

Answer 13

esophageal
caput medusae
hemorrhoids
other locations

Question 14

varices treatment goal and specific agents/procedures

Answer 14

goal is to reduce risk of bleeding

1) nonselective B-blockers (propran, nad, carved _olol) “PROPer CARVED NADs”
highest dose tolerable
B1+B2 (2=unopposed alpha reduces inflow via vasoconstriction, 1=slows heart and CO)
2) band ligation

Question 15

variceal bleeding treatment

Answer 15

antibiotics
octreotide - reduces portal HTN via splan vasodilat
bands
TIPS for recurrent

Question 16

hepatic encephalophaty - what substances cause it and why does it occur?

Answer 16

ammonia + toxins from bacteria in intestines

bypass liver via shunts (TIPS increases) AND bad liver function

Question 17

what type of patient gets hepatic encepahlopathy? what occurs in the brain? treatment?

Answer 17

acute liver failure; edema and herniation; use dialysis

brain adapts to chronic liver cirrhosis

Question 18

hepatic encephalopahty presentation

Answer 18

1) confusion
2) somnolence
3) asterixis - flapping when hand is up with wrist flexed back

Question 19

treatment of hepatic encephalopathy

Answer 19

1) reduce gut bacteria –> rifaximin
2) trap ammonia –> lactulose (ionizes), zinc
3) never protein restrict

Question 20

what type of blood supply does HCC have? does it occur with or without cirrhosis ?

Answer 20

arterial - can be diagnostic w/out biopsy AND used to treat

always occurs with cirrhosis

Question 21

how often should cirrhosis get imaged for HCC?

Answer 21

every 6 months with advanced fibrosis and cirrhosis

Question 22

HRS patient findings

Answer 22

ascites
hypotension
low urine output
hyponatremia