158b - Complications of Cirrhosis (probably taking the L on this one tbh)

Question 1

List 3 physical exam signs of cirrhosis w/portal htn

Answer 1

• Cognitive errors/slowness
• Fluid retention: Abdominal fullness, leg swelling, weight gain
• Fatigue

Question 2

What is the major difference in the pathogenesis of hepatopulmonary syndrome and portopulmonary HTN?

Answer 2

• Hepatopulmonary syndrome
  
  • Portal HTN -> Vasodilation
  • Shunting around the lungs
  • Hypoxemic arterial blood
• Portopulmonary HTN
  
  • Portal HTN -> Constriction of arteries in the lung
  • -> Pulmonary HTN
  • Right heart failure

They are kind of opposites, but can co-occur

Question 3

What is the first-line treatment for hepatic encephalopathy?

Answer 3

Lactulose

• Increases bowel movements (gets rid fo ammonia)
• Traps NH4+ in the GI lumen for excretion
  
  • Bacteria metabolize -> acidify lumen -> trap NH4+ in ionized form (cannot be absorbed)
• Pre-biotic

Question 4

What is a hepatic hydrothorax?

What causes it?

Answer 4

Increased pleural fluid

• Portal HTN -> Ascites
• Intrathoracic pressure < intra-abdominal pressure, fluid get through rents in the diaphragm to the pleural space

Question 5

Which extra-hepatic complication of cirrhosis is driven by vasoconstriction?

Answer 5

Portopulmonary hypertension

Basically everything else is due to NO release -> vasodilation -> decreased perfusion to important organs (lung, kidney)

(Honestly this lecture was beyond me, good luck everyone <3)

(Pulmonary HTN in the setting of portal HTN)

Question 6

What cells constitute a positive culture for bacterial peritonitis?

Answer 6

Neutrophils

(Even if cultures are negative)

Question 7

What is hepatorenal syndrome?

Answer 7

Decreased renal perfusion in the setting of severe portal HTN

• Portal HTN
• -> NO release
• -> Vasodilation
  
  • More blood in the veins, less in the arteries
• -> Renal vasoconstriction, RAAS activation
• -> Less perfusion to kidneys

Question 8

What is hepatopulmonary syndrome?

Answer 8

Portal HTN-induced pulmonary shunting

Non-oxygenated blood is shunted around the lung, leading to hypoxemic arterial blood

Question 9

Describe the pathophysiology of ascites

Answer 9

Due to increasing portal HTN, liver fluids leak into the peritioneum

• Portal htn
• NO release
• Vasodilation
• Decreased renal perfusion
• RAAS activation
• Fluid retention
• Increased portal HTN