337 Cirrhosis Flashcards
58M known cirrhotic sec to chronic HBV infection presents with severe generalized abdominal pain. He is on spironolactone, furosemide and propanolol. PE +icteric sclera, distended abdomen with positive fluid wave, and shifting dullness and tenderness on all quadrants. If peritoneal fluid culture yielded E. Coli and Enterococcus sp., what will be the next step? A. broad spectrum antibiotics B. abdominal radiography C. repeat culture D. Refer to surgery
D. Refer to surgery
Culture point to ruptured viscus
Regardless of cause, what is the pathologic feature of cirrhosis
Development of fibrosis to the point ot architecturL distortion with the formation of regenerative nodules
Significant complicating feature of decompensated cirrhosis and is responsible for development of ascites and bleeding from esophageal varices
Portal hypertension
What is the diameter of the nodules in alcoholic cirrhosis
Nodules usually less than 3 mm in diameter
Where is ethanol mainly absorbed
Small intestines
Majority of ethanol oxidation occurs where
ADH
3 enzyme system that account for metabolism of alcohol in the liver
- Cytosolic ADH
- Microsomal ethanol oxidizing system (MEOS)
- Peroxismal catalase
Highly reactive molecule oxidized from ethanol
Acetaldehyde
Unique form of hemolytic anemia in patients with severe alcoholic hepatitis charcaterised by spur cells and acanthocytes
Zieve’s syndrome
AST ALT ratio which point to alcoholic cirrhosis
AST/ALT ratio 2:1
Cornerstone therapy for patients with alcoholic liver disease
Abstinence
Other therapy for alcolohic cirrhosis which decrease production of TNF alpha
Pentoxifylline
Grams of acetaminophen that may be given to patient with liver disease
4 grams per day
How many percent of HCV will develop chronic HCV and how many will develop cirrhosis
HCV 80% become chronic then 20-30% develop cirrhosis
Factors that point to severe complications of interferon based therapy
Platelet less than 100K
Albumin less than 3.5 g/dl
MELD score more than 10
Test for autoimmune hepatitis
ANA or
Anti smooth muscle antibody (ASMA)
Major causes of chronic cholestatic syndromes
Primary biliary cirrhosis
Autoimmune cholangitis
Primary sclerosing cholangitis
Idiopathic adulthood ductopenia
Characterized by portal inflammation and necrosis of cholangiocytes in small and medium sized bile ducts
Primary biliary cirrhosis
Treatment of choice for decompensated cirrhosis from PBC
Liver transplantation
Is the only approved treatment for PBV by slowing the rate of progression of the disease
UDCA
Antibodies present in 90% of PBC
Antimitochondrial antibodies (AMA)
4 stages of Primary Biliary cirrhosis
- Chronic nonsuppurative destructive cholangitis
- Involving peri portal areas
- Bridging fibrosis
- Cirrhosis
Seen in approx 50% of patients with PBC
Pruritus
True or false. Pruritus that presents prior to development of jaundice indicated milder disease
False. Severe disease and poor prognosis
Dosage of UDCA in PBC
13-15 mg/kg/day
How is pruritus treated in patients with PBC
Antihistamines
Narcotic receptor antagonist (naltrexone)
Rifampicin
Cholestyramine
Chronic cholestatic syndrome characterized by diffuse inflammation and fibrosis involving the entire biliary tree resulting in chronic cholestasis
Primary sclerosing cholangitis
What is concurrent in patient with PSC and what investigations should be done
PSC will have overlap with AIHA
50% of patients with PSC will have uclerative colitis thus Colonoscopy is peformed
What is the typical cholangiographic findings in PSC
Multifocal sticturing and beading involving the intrahepatic and extra hepatic biliary tree. Strictures are typically short and with intervening segments of normal or slightly dilated bile ducts
Dreaded complication of PSC
Cholangiocarcinoma
What is the pathology of cardiac cirrhosis
Elevated venous pressure transmitted via the Inferior vena cava and hepatic veins to the sinusoids of the liver which became dilated and engorged with blood. Liver becomes enlarged and swollen
True or false. Patient with cardiac cirrhosis will also have chances of developing variceal hemorrhage and encephalopathy
False. It is unlikely patient will develop variceal hemorrhage or encephalopathy
Difference between cardiac hepatopathy and Budd Chiari Syndrome
In Budd Chiari Syndrome there is extravasation of RBC
Inherited disorder of iron metabolism that results in progressive increase in hepatic iron deposition which over time can lead to portal based fibrosis progressing to cirrhosis
Hemochromatosis
Major complication of cirrhosis
- Portal hypertension
- Gastroesoohageal variceal hemorrhage
- Splenomegaly
- Ascites
- Hepatic Encephalopathy
- SBP
- Hepatorenal syndrome
- HCC
Definition of portal hypertension
Elevation of hepatic venous pressure gradient to (HVPG) to more than 5 mmHg
What is the pathophysiology of portal hypertension
- Increased intrahepatic resistance to passage of blood
2. Increased splanchnic blood flow secondary to vasodilation within splanchnic vascular bed
Complications directly related to portal hypertension
- Variceal hemorrhage
2. Ascites
Immediate life threatening problem in portal hypertension with a 20-30% Mortality rate
Variceal hemorrhage
