Advanced liver disease Flashcards
What are the two major types of consequences resulting from cirrhosis?
Impaired detox/metabolic/excretory capatiy
Hemodynamic changes
Examples of findings you’d see with impaired liver function?
- hypoalbuminemia
- coagulopathy
- hyperammonia
- hypoglycemia
- Jaundice
- Gynecomastia
What is the definition of cirrhosis?
Scarred liver with fibrotic bands
Is Cirrhosis reversible?
Traditionally, we thought no. But new treatment options may change outcome and some reversibility. Also, liver transplant.
Describe the pathophysiology behind portal hypertension
- Increased resistance to portal venous flow (constriction)
2. Increased portal venous blood
What test is STRONGLY suggestive of decompensated cirrhosis/
Serum-Ascites Albumin gradient
What is the definition of portal hypertension?
Portal venous pressure gradient > 5 mm Hg
What are the most common causes of cirrhosis?
Liver disease
Non-cirrhotic portal HTN
Extrahepatic liver disease
What are the most common causes of liver disease?
- Alcohol
- Viral hepatitis (B+C)
- Schistosomiasis
4.
What are common causes of non-cirrhotic portal hypertension?
Idiopathic, seen in India/Japan. Usually a vascular coagulopathy.
What are common causes of extrahepatic portal hypertension?
Portal vein block caused by tumor/splenomegaly
How do you diagnose portal hypertension?
Measure it using either:
- Direct catheterization of portal vein
- Indirectly with wedged hepatic pressure recording. Transfemoral catheterization of hepatic bein
Are you vasoconstricted or vasodilated in portal hypertension?
Increased resistance in liver
- ->dilatation peripherally and in splanchnic from NO (hypotension)
- ->constriction of hepatic vessels and renal vessels, from release of endothelin and other constrictors
How do you calculate the wedge pressure gradient?
Difference between:
1. Wedge minus free hepatic vein pressure
What pathogen can cause portal hypertension?
Schistosomiasis: Can cause granulomas to form in the kidney
What would you see as a result of peripheral vasodilation?
Well perfused skin
Low BP
What would you see with splanchnic vasodilation?
Increased collateral flow/GI permeability=more bacteria
What would you see with increased central vasoconstriction?
Brain dysfunction Hepatorenal syndrome (decreased renal flow) Hepatopulmonary syndrome (vasodilation of lungs=hypoxia)
What drugs might you use for portal HTN?
- Beta-blockers=less shear force
- alpha-agonist: Treats excessive peripheral vasodilation
- anti-inflammatory for liver dz
- Surgical shunt
What causes a high bleeding risk in pts with liver dz?
Esophageal/gastric varices
How do you treat varices?
Banding sclerotherapy
TIPS divert portal blood flow into the hepatic vein
What classification system can you use to characterize liver disease?
Child-Pugh gives A/B/C scores
What are the components of the child-pugh classification?
- Ascites
- Encephalopathy
- Albumin
- Bilirubin
- PT
What’s the difference between a non-selective vs selective shunt?
Selective shunts still allow all intestinal flow to go through the liver. Redirects splenic vein.
What is your goal in treating PHT?
Reduce portal pressure < 12 mmHg
What medical therapy is available for PHT?
beta blockers (non-selective)
How do you treat a bleeding varices?
- Resuscitate w/ fluid/somatostatin/intubation
- Endoscopy within 12 hrs
- If esophageal, use acute banding. If gastric, use TIPS
What is the mortality rate from variceal bleeding?
30-40%
–Most often, bleeding due to ulcers, not varices
Causes of Ascites+peritoneal disease?
malignancy/inflammation
Causes of ascites sine peritoneal disease?
Liver dz/vascular blockage
OR hypoalbuminemia
What are causes of ascites from parenchymal liver dz?
- decompensated cirrhosis
- alcoholic hepatitis
- drugs/herbs
Describe the pathophysiology behind PHT/ascites
- cirrhosis
- hypoalbuminemia
- 3rd space fluid
- Intravascular volume depletion
- RAAS activation
- Retention of water and salt
Describe the secondary process contributing to ascites
Vasoconstriction of renal vessels=water/salt retention
AND
systemic/splanchnic vasodilation=volume expansion
What lab values would you see in hepatorenal syndrome?
HIGH aldo
High renin
Low urine Na
Low creatinine clerance
What tests would you run on diagnostic paracentesis?
albumin, WBC + diff, Total protein. Consider gram stain/culture, bilirubin, Hgb
When should you get a diagnostic paracentesis?
In every patient with ascites. Also, get an abdominal CT/US to determine if liver cause.
What would cause a high WBC in paracentesis?
infection or malignancy
What would cause a high TP?
infection, malignancy, cardiac failure, hypothyroidism.
How would you manage ascites?
Spironolcatone
Furosemide
OR
Large volume paracentesis
What is the problem with using diuretics in ascites?
Can worsen renal failure (hepatorenal syndrome) as well as electrolyte disturbances
What is the problem with using high volume paracentesis?
Renal failure if draining a TON…if caused by CHF, beneficial. If liver dz, then rapid diuresis can be bad…
What are your options in intractable ascites?
TIPS or liver transplantation
Why are pts with advanced liver disease complicated pts?
Pts are in a very fine balance btw vasodilation/constriction. NSAIDS/UTIs can cause renal failure.
