6. Cirrhosis

Question 1

LO1: Dx Cirrhosis based on PE (10)

Answer 1

1) Scleral icterus
2) Jaundice
3) Spider angioma
4) Caput medusae
5) Umbilical hernia
6) Enlarged left lobe of liver
7) Gynecomastia
8) Splenomegaly
9) ascites
10) Dupuytren’s contractures-ring finger tendon

Question 2

LO1: Dx Cirrhosis based on labs: Liver insuffiency (3), Portal HTN (1)

Answer 2

Liver Insufficiency
1) Low albumin (<3.8 g/dL)
2) INR > 1.3
3) Bili >1.5 mg/dL
Portal HTN
1) Low Plt <150,00

Question 3

LO1: Dx Cirrhosis based on rad -CT/US/MRI (6)

Answer 3

1) Nodular Liver
2) Caudate hypertrophy
3) Ascites
4) Splenomegaly
5) Venous Collaterals
6) Hepatocellular carcinoma

Question 4

LO2: Portal HTN in Cirrhosis -> varices (5)

Answer 4

1) Cirrhosis->
2) Increased resistance to portal flow ->
3) Increased portal pressure ->
4) Varices ->
5) Variceal growth

Question 5

LO3: Dx ascites due to portal HTN

Routine (4), Optional (7)

Answer 5

1) US- most sensitive
Routine
2) albumin
Protein
3) PMN cell count
4) Bx cultures
Optional
1) Glucose
2) LDH
3) Amylase
4) RBC
5) TB smear
6) cytology
7) TG

Question 6

LO3: Dx ascites due to bx peritonitis (2)

Answer 6

1) Ascitic fluid w/ PMN count > 250/mm^2

2) Tx only indicated when culture is positive

Question 7

LO4: Mechanism for developing hepatic encephalopathy (5)

Answer 7

1) Increased Ammonia crosses BBB
2) Increase astrocytic peripheral benzodiazepine -R
3) Neurosteroid production
4) Modulation of GABAa-R -> cortical depression
5) Hepatic Encephalopathy

Question 8

LO4: Risk factors for worsening hepatic encephalopathy (5)

Answer 8

1) Excess protein
2) TIPS
3) gI bleed
4) Sedatives/hypnotics
5) Diuretics -> decrease Serum K -> Plasma volume down-> azotemia

Question 9

LO5: Components of MELD score (3)

Answer 9

1) INR
2) Serum Cr
3) Serum total bili
- estimates 3 month mortality

Question 10

LO5: MELD score use in ranking Transplant Pts (4)

Answer 10

1) Fulminant hepatic failure - highest priority
2) Same blood -highest MELD determines priority
3) Wait time used to break ties of = MELD
4) MELD updated at regular intervals

Question 11

Mechanisms of portal HTN in cirrhosis (sinusoidal) (1ab, 2a)

Answer 11

1) Increased intrahepatic resistance (initial)
a) Structural -fibrosis, regenerative nodules
b) Active vasoconstrict - decrease NO, increase vasoconstrictors
2) Increased portal venous inflow
a) splanchnic vasodilation -increased NO

Question 12

Sinusoidal obstructive syndrome (3)

Answer 12

1) Small hepatic veins obstructed
2) Complication of myeloablative regimens for bone marrow transplant
3) RUQ pn, ascites, HM, jaundice

Question 13

Budd-Chiari Syndrome (3)

Answer 13

1) Obstruction of hepatic veins -small, large, IVC
2) Often from thrombosis due to hypercoagulability
3) Abd pn, ascites, edema

Question 14

LO2: Portal HTN in Cirrhosis -> Ascites (7)

Answer 14

1) Portal HTN ->
2) Shear stress ->
3) Increased NO
4) Vasodilation-decrease SVR ->
5) Activate RAAS ->
6) Na and H20 retention ->
7) Ascites

Question 15

Portal Pressure Measurement (2)

Answer 15

1) Definitive for dx portal HTN

2) HVPG (NL 3-5 mmHg) -hepatic venous pressure gradient

Question 16

HVPG in DDx of portal HTN (2)

Answer 16

1) NL - pre-hepatic, pre-sinusoidal, and post-hepatic

2) Elevated - sinusoidal and post-sinusoidal

Question 17

HVPG formula

Answer 17

HVPG = Wedged hepatic venous pressure (WHVP) - free hepatic venous pressure (FHVP)
FHVP - internal 0 to correct for extravascular pressure increase

Question 18

TIPS?

Answer 18

Transjugular intrahepatic Portosystemic shunt

Question 19

Variceal Tx (5)

Answer 19

1) Vasoconstrictors (octreotide)
2) venodilators
3) Vasoconstrict + venodilate
4) Endoscopic tx
5) TIPS

Question 20

Ascites Tx (1, 2b, 3b)

Answer 20

1) Portal HTN no ascites-consider Na retention
2) Uncomplicated ascites
a) Na restriction + diuretics
b) Large volume paracentesis (LVP) w/ tense ascites
3) Refractory Ascites
a) LVP + albumin
b) TIPS

Question 21

Refractory Ascites Types (2)

Answer 21

1) Diuretic -intractable ascites (80%) - therapeutic doses not possible due to diuretic complications
2) Diuretic-resistant ascites - No response to maximal spironolactone and furosemide

Question 22

Hepatorenal Syndrome (4)

Answer 22

1) Renal failure in pts w cirrhosis
2) absence of significant histo changes -fxnl renal failure
3) marked arteriolar vasodilation in extra-renal circulation
4) Marked renal vasoconstriction leading to reduced GFR

Question 23

Dx hepatorenal syndrome (6)

Answer 23

1) advanced hepatic failure and portal HTN
2) Cr> 1.5 or Crcl < 40
3) Absence of shock, bx infxn or nephrotoxic drug
4) Absence of excessive GI or renal loss
5) No renal fxn improvement after plasma volume expansion
6) Urinary protein < 500 and nl renal US

Question 24

What is always present in HRS? (2)

Answer 24

AScites

Hyponatremia (almost universal)

Question 25

Mechanism to ascites, hepatorenal syndrome, and hyponatremia (3)

Answer 25

Cirrhosis -> Activate RAAS->

1) Sodium retention =ascites
2) renal vasoconstriction = hepatorenal syndrome
3) water retention = hyponatremia

Question 26

HRS management (1, 2)

Answer 26

1) Liver Transplant -proven
Under investigation
1) Vasoconstrictor + albumin
2) TIPS

Question 27

Ascites Clinical Picture (6)

Answer 27

1) Fever
2) Jaundice
3) abd pn
4) AMS
5) abd tenderness
6) Hypotension

Question 28

Spontaneous Bacterial Peritonitis (2)

Answer 28

1) Mostly occurs by bacterial translocation

2) Microorganisms from gut lumen to mesenteric LN and extraintestinal organs

Question 29

SBP Tx (3)

Answer 29

1) empiric antibx avoid AG
2) 5 days minimum
3) reevaluate if PMN has not decreased by 25%

Question 30

Hepatic Encephaopathy? (5)

Answer 30

1) Neuropsych complication fo cirrhosis
2) Results from
a) Portosystemic shunt
b) Chronic liver failure
3) Failure to metabolize neurotoxins
4) Astrocyte morphology and fxn alteration
5) Clinical Dx

Question 31

Hepatic encephaopathy Tx (3)

Answer 31

1) Identify cause
2) Lactulose
3) Protein restriction, short term

Question 32

Serum albumin gradient (SAAG)

Answer 32

Serum-Ascites Albumin Gradient. Serum Albumin - Ascites Albumin