337 - Cirrhosis and Its Complications

Question 1

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.

Answer 1

Fibrosis 
Stellate
Architecture
Collagen 
Nodules
Mass

Question 2

Liver cirrhosis can be classified into ___ and ___. The latter has a decrease in ___ and we should consider ___

Answer 2

Compensated
Uncompensated
Liver function
Liver transplantation

Question 3

____ of liver cirrhosis represent the severity of the disease, while staging and grading are defined by ____.

Answer 3

Clinical symptoms

Biopsy

Question 4

Hepatocellular injury may lead to: (4)

Answer 4

1. Jaundice
2. Hemostasis dysfunction
3. Hypoalbuminemia
4. Encephalopathy

Question 5

In uncompensated liver cirrhosis we will see ___ which in turns leads to __ and ___ bleeding.

Answer 5

Portal HTN
Varices
Varices

Question 6

What are the 3 enzyme systems metabolizing alcohol?

Answer 6

ADH
MEOS
Peroxisomal catalase

Question 7

Alcohol consumption may lead to activation of___ that create fibrinogenic cytokines which promote ___ activation and excessive synthesis of __ and ___

Answer 7

Kupffer cells
Stellate
Collagen
ECM

Question 8

Alcohol injury leads to the formation of connective tissue between the ____ to the main ___ and creates regenerative ___

Answer 8

Portal triad
Vein
Nodules

Question 9

Alcohol cirrhosis is a process that progresses for ___ and leads to loss of ___ and decrease in ___ size

Answer 9

Years
Hepatocytes
Liver

Question 10

Ethanol also increases the accumulation of ___ due to an increase in its ___, decrease in fatty acid ___ and damage in ____ secretion.

Answer 10

Triglycerides
Absorption
Oxidation
lipoproteins

Question 11

General clinical symptoms of alcohol induced liver cirrhosis include: (5)

Answer 11

1. Fever
2. Anorexia
3. RUQ dull pain
4. Nausea/vomiting
5. Diarrheas

Question 12

Specific clinical symptoms of alcohol induced liver cirrhosis include: (5)

Answer 12

1. Encephalopathy
2. Jaundice
3. Ascites
4. GI bleeding
5. Edema

Question 13

Physical examination of a patient with alcohol induced liver cirrhosis include: (5)

Answer 13

1. Parotid enlargement
2. Palmar erythema
3. Clubbing
4. Spider angioma
5. Edema/ascites

Question 14

In men with alcohol induced liver cirrhosis we can see body___ loss, ___ and ___atrophy due to hormonal changes

Answer 14

Hair
Gynecomastia
Testicular

Question 15

Lab results of alcohol induced liver cirrhosis may present: ANTI2 (5)

Answer 15

1. Anemia
2. Nutritional deficiency
3. Thrombocytopenia
4. Increased direct bilirubin
5. Increased AST and ALT

Question 16

Diagnosis of alcohol induced liver cirrhosis can be made with ____. Only __ months after rehabilitation another biopsy should be made to determine the severity of

Answer 16

Biopsy

6

Question 17

The best treatment for alcohol induced liver cirrhosis is ___. Drugs that can be used include: (3)

Answer 17

Alcohol absenteeism
Absenteeism calcium
Glucocorticoids
N-acetylcysteine

Question 18

After exposure to ____, ____ of patients will develop chronic hepatitis, of them ___ will continue to ____

Answer 18

HCV
80%
20-30%
Liver cirrhosis

Question 19

After HBV exposure, ___ of patients will develop chronic hepatitis, of them ___ will continue to ___

Answer 19

5%
20%
Liver cirrhosis

Question 20

In chronic HBV we will see positive ___ and ___, and possibly hepatocytes with ground glass appearance in imaging tests

Answer 20

HBc-Ag

HBs- Ag

Question 21

Chronic HBV can be treated with ___, helping preventing the shift from _____ to uncompensated cirrhosis

Answer 21

Anti viral drugs

Compensated

Question 22

Chronic HCV can be treated with the very expensive ___ protocol (95% cure rate) for a relative short period of ____ weeks

Answer 22

Anti viral

8-12

Question 23

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.

Answer 23

Auto immune Hepatitis
ANA
ASMA
Immunosuppressive

Question 24

NAFLD stands for____. Most patients have ____

Answer 24

Non-alcoholic fatty liver disease

Steatohepatitis

Question 25

Cholestatic disease can be ___ or ____. In the latter we can treat with ___ or ___.

Answer 25

Intrahepatic Extrahepatic Surgery Endoscopy

Question 26

The main etiologies for cholestatic disease are: (4)

Answer 26

1. PBC (Primary biliary cholangitis) 2. AIC (Auto immune cholangitis) 3. PSC (Primary sclerosing cholangitis) 4. Idiopathic

Question 27

The cause leading to PBC is unknown. It is common in ___ over the age of ___. Characterized by ____ and __ together with ____ and ____

Answer 27

``` Women 50 Portal inflammation Necrosis of small/medium bile tubeless Cholestatic characteristics Elevated bilirubin ```

Question 28

What is the recommended treatment for PBV patients with uncompensated liver cirrhosis? What can slow down the progression of the disease?

Answer 28

Liver transplantation | UDCA (ursodeoxycholic acid)

Question 29

Most PBC patients will present ___ antibodies

Answer 29

AMA (Anti mitochondrial membrane antibodies)

Question 30

Most PBC patients are diagnosed in the asymptomatic state with general symptoms including: (3)

Answer 30

Hepatosplenomegaly Aseities Edema

Question 31

Specific PBC symptoms include: (4)

Answer 31

1. Fatigue 2. Pruritus (mostly in the evenings) 3. Cholesterol metabolism dysfunction 4. Bone pain

Question 32

Lab results of PBC patients will include: (5)

Answer 32

1. Cholestatic liver enzymes elevation (GGT,ALP,AST,ALT) 2. Immunoglobulins elevation (IgM) 3. Hyperbilirubinemia 4. Pancytopenia 5. AIH characteristics

Question 33

PBC treatment include ___ which is crucial to initiate ASAP. It does not lead to ___ and is ineffective once ___ symptoms start.

Answer 33

UDCA Cure Liver cirrhosis

Question 34

UDCA S/E include: (3)

Answer 34

1. Pruritus 2. Diarrhea 3. Headache

Question 35

Once a PBC patient is in the ____ stage, consider ____

Answer 35

Uncompensated liver cirrhosis | Liver transplantation

Question 36

PSC (Primary sclerosing cholangitis) is characterized by ___ and ___ in the entire biliary tree (___ and ___) causing chronic cholestasis and eventually- ___

Answer 36

Chronic diffuse inflammation Fibrosis Intra and extra hepatic Cirrhosis

Question 37

Clinical signs of PSC include: (5)

Answer 37

1. Fatigue 2. Pruritus 3. Steatorrhea 4. ADEK vitamin deficiency 5. Metabolic bone deficiency

Question 38

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.

Answer 38

``` ALP AST/ALT Albumin PTT Aminotransferase ```

Question 39

In PSC ____ will be positive in 65% of patients. up to 50% will be diagnosed with ___ as well, therefore ___ is necessary when diagnosed

Answer 39

p-ANCA UC Colonoscopy

Question 40

In order to diagnose PSC ___ must be made, first with ___ followed by ___ in order to check for strictures.

Answer 40

Cholangiography imaging MRCP ERCP

Question 41

Typical findings of PSC imaging include ____ of the bile ducts. the ___ and ___ can be involved in 15% of casese

Answer 41

Beading Cystic duct Gallbladder

Question 42

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 ____.

Answer 42

UDCA dilatation Liver transplantation

Question 43

Right side HF leading to increase pressure on the ___ and ___ may lead to ____

Answer 43

IVC Hepatic ducts Cirrhosis

Question 44

Mention 4 more types of liver cirrhosis:

Answer 44

1. Hemochromatosis 2. Wilson's disease 3. Alpha1 AT deficiency 4. Cystic Fibrosis

Question 45

What are the steps in classification of portal hypertension?

Answer 45

Prehepatic-> Hepatic (presinusoidal, sinusoidal, postsinusoidal)-> Posthepatic-> Cardiac.

Question 46

The main complications of portal hypertension are ___, ____, ____, and ___

Answer 46

Esophageal varices Ascites Edema Hypersplenism

Question 47

Bleeding varices is a ___ with mortality of ___ in each bleeding event.

Answer 47

Life threatening event | 20-30%

Question 48

Screening tests is necessary in patients with liver cirrhosis because most of them will develop ___ in during their lifetime and __ of them will bleed.

Answer 48

Varices | 1/3

Question 49

Risk factors for varices bleeding include: (5)

Answer 49

1. Cirrhosis severity (Child's Pugh/MELD) 2. Ascites 3. Wedge hepatic vein pressure 4. Location and size 5. Cherry red spots/white nipple spots

Question 50

If we diagnose varices which are prone to bleed in liver cirrhosis patient we can either administrate ___ or ___

Answer 50

Non selective Beta blockers | Variceal band ligation

Question 51

When varices are actively bleeding we must first ___. First line will be ___ or ___. Additionally we must administrate ___ and ___

Answer 51

``` Stop the bleeding Scleropathy Band ligation Blood Fluids ```

Question 52

Further varices bleeding is prevented via additional ___ of the varices (EVL). To stop the bleeding, drugs such as ___ and ____. Other mechanical wats can be

Answer 52

Ligation Somatostatin Octreotide Balloon

Question 53

When varices are persistent, consider TIPS (___). Of these patients, ___ will develop encephalopathy. This treatment could be a bridge before ____

Answer 53

Transjugular intrahepatic portosystemic shunt 20% Liver transplantation

Question 54

SAAG above 1.1 g/dL suggests

Answer 54

Portal HTN

Question 55

SAAG under 1.1 g/dL suggests

Answer 55

Infection/malignancy

Question 56

In ascites there will be a low concentration of ___, usually < ___ g/dL. When very low there's a risk for ___

Answer 56

Protein 1 SBP (spontaneous bacterial infection)

Question 57

In ascites with PMN>250-

Answer 57

Infected fluid

Question 58

In small ascites we can treat with ___ reduction (< __ ). Medium size- diuretics such as ____ and if needed add ___. If the ascites persists consider ___ or ___

Answer 58

``` Salt 2 mg/day Spironolactone Furosemide Drainage TIPS ```

Question 59

What are the common pathogens leading to SBP? (4)

Answer 59

1. E. Coli 2. Strep Viridans 3. Staph aureus 4. Enterococcus

Question 60

What should we suspect when more than 2 pathogens are diagnosed in ascites fluid?

Answer 60

Peritoneal infection due to perforation

Question 61

What is the treatment for SBP?

Answer 61

3rd gen cephalosporin (ceftriaxone)

Question 62

What is hepatorenal syndrome?

Answer 62

Functional renal failure without renal pathology, caused by a disturbance in the arterial renal circulation.

Question 63

How do you diagnose hepatorenal syndrome?

Answer 63

A large ascites with gradual increase in Cr.

Question 64

What is type 1 hepatorenal syndrome?

Answer 64

Gradual damage in renal function and a drastic decrease in Cr clearance within 2 weeks

Question 65

What is type 2 hepatorenal syndrome?

Answer 65

Decrease in GFR and an increase in Cr clearance in a stable fashion- better prognosis

Question 66

What is the treatment for hepatorenal syndrome? (4)

Answer 66

Midodrine (Alpha agonist) Octreotide Albumin IV Liver transplantation (best treatment)

Question 67

What is liver encephalopathy?

Answer 67

Mental state changes due to liver failure

Question 68

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 ___

Answer 68

Ammonia | Diagnosis

Question 69

Diagnosis is ___, with ___ being one of the signs.

Answer 69

Clinical | Asterixis

Question 70

In sever cases we can see ___, that may lead to ___. Therefore we should treat it with ___ and ___.

Answer 70

Brain edema Herniation Mannitol Fluids IV

Question 71

Encephalopathy can appear within weeks to months and is usually preceded by ___, ___, ___ or ___.

Answer 71

Hypokalemia Infection Increase in protein consumption Electrolytes disturbance

Question 72

The main treatment for encephalopathy is ___. It leads to ____ of the and prevents absorption of ____agents.

Answer 72

Lactulose Acidification Colon Toxic

Question 73

Beside lactulose we can treat encephalopathy with: (2)

Answer 73

Rifaximin (unobservable Abx) | Zinc