337 - Cirrhosis and Its Complications Flashcards
Cirrhosis pathology includes ___ due to activation of ___ cell in the liver which produce ___- leading to changes in the liver’s ___ together with ___ formation, decrease in liver ___ and function, blood flow changes.
Fibrosis Stellate Architecture Collagen Nodules Mass
Liver cirrhosis can be classified into ___ and ___. The latter has a decrease in ___ and we should consider ___
Compensated
Uncompensated
Liver function
Liver transplantation
____ of liver cirrhosis represent the severity of the disease, while staging and grading are defined by ____.
Clinical symptoms
Biopsy
Hepatocellular injury may lead to: (4)
- Jaundice
- Hemostasis dysfunction
- Hypoalbuminemia
- Encephalopathy
In uncompensated liver cirrhosis we will see ___ which in turns leads to __ and ___ bleeding.
Portal HTN
Varices
Varices
What are the 3 enzyme systems metabolizing alcohol?
ADH
MEOS
Peroxisomal catalase
Alcohol consumption may lead to activation of___ that create fibrinogenic cytokines which promote ___ activation and excessive synthesis of __ and ___
Kupffer cells
Stellate
Collagen
ECM
Alcohol injury leads to the formation of connective tissue between the ____ to the main ___ and creates regenerative ___
Portal triad
Vein
Nodules
Alcohol cirrhosis is a process that progresses for ___ and leads to loss of ___ and decrease in ___ size
Years
Hepatocytes
Liver
Ethanol also increases the accumulation of ___ due to an increase in its ___, decrease in fatty acid ___ and damage in ____ secretion.
Triglycerides
Absorption
Oxidation
lipoproteins
General clinical symptoms of alcohol induced liver cirrhosis include: (5)
- Fever
- Anorexia
- RUQ dull pain
- Nausea/vomiting
- Diarrheas
Specific clinical symptoms of alcohol induced liver cirrhosis include: (5)
- Encephalopathy
- Jaundice
- Ascites
- GI bleeding
- Edema
Physical examination of a patient with alcohol induced liver cirrhosis include: (5)
- Parotid enlargement
- Palmar erythema
- Clubbing
- Spider angioma
- Edema/ascites
In men with alcohol induced liver cirrhosis we can see body___ loss, ___ and ___atrophy due to hormonal changes
Hair
Gynecomastia
Testicular
Lab results of alcohol induced liver cirrhosis may present: ANTI2 (5)
- Anemia
- Nutritional deficiency
- Thrombocytopenia
- Increased direct bilirubin
- Increased AST and ALT
Diagnosis of alcohol induced liver cirrhosis can be made with ____. Only __ months after rehabilitation another biopsy should be made to determine the severity of
Biopsy
6
The best treatment for alcohol induced liver cirrhosis is ___. Drugs that can be used include: (3)
Alcohol absenteeism
Absenteeism calcium
Glucocorticoids
N-acetylcysteine
After exposure to ____, ____ of patients will develop chronic hepatitis, of them ___ will continue to ____
HCV
80%
20-30%
Liver cirrhosis
After HBV exposure, ___ of patients will develop chronic hepatitis, of them ___ will continue to ___
5%
20%
Liver cirrhosis
In chronic HBV we will see positive ___ and ___, and possibly hepatocytes with ground glass appearance in imaging tests
HBc-Ag
HBs- Ag
Chronic HBV can be treated with ___, helping preventing the shift from _____ to uncompensated cirrhosis
Anti viral drugs
Compensated
Chronic HCV can be treated with the very expensive ___ protocol (95% cure rate) for a relative short period of ____ weeks
Anti viral
8-12
AIH stands for____. Diagnosis will require autoimmune markers such as: ___ and ___. If the patients are suffering from cirrhosis in tandem with active inflammation and elevated liver enzymes- treat with ___ drugs.
Auto immune Hepatitis
ANA
ASMA
Immunosuppressive
NAFLD stands for____. Most patients have ____
Non-alcoholic fatty liver disease
Steatohepatitis
Cholestatic disease can be ___ or ____. In the latter we can treat with ___ or ___.
Intrahepatic
Extrahepatic
Surgery
Endoscopy
The main etiologies for cholestatic disease are: (4)
- PBC (Primary biliary cholangitis)
- AIC (Auto immune cholangitis)
- PSC (Primary sclerosing cholangitis)
- Idiopathic
The cause leading to PBC is unknown. It is common in ___ over the age of ___. Characterized by ____ and __ together with ____ and ____
Women 50 Portal inflammation Necrosis of small/medium bile tubeless Cholestatic characteristics Elevated bilirubin
What is the recommended treatment for PBV patients with uncompensated liver cirrhosis? What can slow down the progression of the disease?
Liver transplantation
UDCA (ursodeoxycholic acid)
Most PBC patients will present ___ antibodies
AMA (Anti mitochondrial membrane antibodies)
Most PBC patients are diagnosed in the asymptomatic state with general symptoms including: (3)
Hepatosplenomegaly
Aseities
Edema
Specific PBC symptoms include: (4)
- Fatigue
- Pruritus (mostly in the evenings)
- Cholesterol metabolism dysfunction
- Bone pain
Lab results of PBC patients will include: (5)
- Cholestatic liver enzymes elevation (GGT,ALP,AST,ALT)
- Immunoglobulins elevation (IgM)
- Hyperbilirubinemia
- Pancytopenia
- AIH characteristics
PBC treatment include ___ which is crucial to initiate ASAP. It does not lead to ___ and is ineffective once ___ symptoms start.
UDCA
Cure
Liver cirrhosis
UDCA S/E include: (3)
- Pruritus
- Diarrhea
- Headache
Once a PBC patient is in the ____ stage, consider ____
Uncompensated liver cirrhosis
Liver transplantation
PSC (Primary sclerosing cholangitis) is characterized by ___ and ___ in the entire biliary tree (___ and ___) causing chronic cholestasis and eventually- ___
Chronic diffuse inflammation
Fibrosis
Intra and extra hepatic
Cirrhosis
Clinical signs of PSC include: (5)
- Fatigue
- Pruritus
- Steatorrhea
- ADEK vitamin deficiency
- Metabolic bone deficiency
Lab results of PSC will show an increase of X2 ___ and slight elevation in ___. Low ____ and elongated ____. ___ will be up to X5 above the upper limit.
ALP AST/ALT Albumin PTT Aminotransferase
In PSC ____ will be positive in 65% of patients. up to 50% will be diagnosed with ___ as well, therefore ___ is necessary when diagnosed
p-ANCA
UC
Colonoscopy
In order to diagnose PSC ___ must be made, first with ___ followed by ___ in order to check for strictures.
Cholangiography imaging
MRCP
ERCP
Typical findings of PSC imaging include ____ of the bile ducts. the ___ and ___ can be involved in 15% of casese
Beading
Cystic duct
Gallbladder
There is no proved treatment for PSC. High dosage of ___ is harmful, but low dosage can be helpful. Additionally, endoscopy ___ can be beneficial . Definitive treatment is ____.
UDCA
dilatation
Liver transplantation
Right side HF leading to increase pressure on the ___ and ___ may lead to ____
IVC
Hepatic ducts
Cirrhosis
Mention 4 more types of liver cirrhosis:
- Hemochromatosis
- Wilson’s disease
- Alpha1 AT deficiency
- Cystic Fibrosis
What are the steps in classification of portal hypertension?
Prehepatic->
Hepatic (presinusoidal, sinusoidal, postsinusoidal)->
Posthepatic->
Cardiac.
The main complications of portal hypertension are ___, ____, ____, and ___
Esophageal varices
Ascites
Edema
Hypersplenism
Bleeding varices is a ___ with mortality of ___ in each bleeding event.
Life threatening event
20-30%
Screening tests is necessary in patients with liver cirrhosis because most of them will develop ___ in during their lifetime and __ of them will bleed.
Varices
1/3
Risk factors for varices bleeding include: (5)
- Cirrhosis severity (Child’s Pugh/MELD)
- Ascites
- Wedge hepatic vein pressure
- Location and size
- Cherry red spots/white nipple spots
If we diagnose varices which are prone to bleed in liver cirrhosis patient we can either administrate ___ or ___
Non selective Beta blockers
Variceal band ligation
When varices are actively bleeding we must first ___. First line will be ___ or ___. Additionally we must administrate ___ and ___
Stop the bleeding Scleropathy Band ligation Blood Fluids
Further varices bleeding is prevented via additional ___ of the varices (EVL). To stop the bleeding, drugs such as ___ and ____. Other mechanical wats can be
Ligation
Somatostatin
Octreotide
Balloon
When varices are persistent, consider TIPS (___). Of these patients, ___ will develop encephalopathy. This treatment could be a bridge before ____
Transjugular intrahepatic portosystemic shunt
20%
Liver transplantation
SAAG above 1.1 g/dL suggests
Portal HTN
SAAG under 1.1 g/dL suggests
Infection/malignancy
In ascites there will be a low concentration of ___, usually < ___ g/dL. When very low there’s a risk for ___
Protein
1
SBP (spontaneous bacterial infection)
In ascites with PMN>250-
Infected fluid
In small ascites we can treat with ___ reduction (< __ ). Medium size- diuretics such as ____ and if needed add ___. If the ascites persists consider ___ or ___
Salt 2 mg/day Spironolactone Furosemide Drainage TIPS
What are the common pathogens leading to SBP? (4)
- E. Coli
- Strep Viridans
- Staph aureus
- Enterococcus
What should we suspect when more than 2 pathogens are diagnosed in ascites fluid?
Peritoneal infection due to perforation
What is the treatment for SBP?
3rd gen cephalosporin (ceftriaxone)
What is hepatorenal syndrome?
Functional renal failure without renal pathology, caused by a disturbance in the arterial renal circulation.
How do you diagnose hepatorenal syndrome?
A large ascites with gradual increase in Cr.
What is type 1 hepatorenal syndrome?
Gradual damage in renal function and a drastic decrease in Cr clearance within 2 weeks
What is type 2 hepatorenal syndrome?
Decrease in GFR and an increase in Cr clearance in a stable fashion- better prognosis
What is the treatment for hepatorenal syndrome? (4)
Midodrine (Alpha agonist)
Octreotide
Albumin IV
Liver transplantation (best treatment)
What is liver encephalopathy?
Mental state changes due to liver failure
Usually in liver encephalopathy there will be high levels of ____, without direct correlation to the severity of the disease, therefore, ammonia is not part of the ___
Ammonia
Diagnosis
Diagnosis is ___, with ___ being one of the signs.
Clinical
Asterixis
In sever cases we can see ___, that may lead to ___. Therefore we should treat it with ___ and ___.
Brain edema
Herniation
Mannitol
Fluids IV
Encephalopathy can appear within weeks to months and is usually preceded by ___, ___, ___ or ___.
Hypokalemia
Infection
Increase in protein consumption
Electrolytes disturbance
The main treatment for encephalopathy is ___. It leads to ____ of the and prevents absorption of ____agents.
Lactulose
Acidification
Colon
Toxic
Beside lactulose we can treat encephalopathy with: (2)
Rifaximin (unobservable Abx)
Zinc
