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Advanced liver disease Flashcards

1
Q

What are the two major types of consequences resulting from cirrhosis?

A

Impaired detox/metabolic/excretory capatiy

Hemodynamic changes

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2
Q

Examples of findings you’d see with impaired liver function?

A
  1. hypoalbuminemia
  2. coagulopathy
  3. hyperammonia
  4. hypoglycemia
  5. Jaundice
  6. Gynecomastia
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3
Q

What is the definition of cirrhosis?

A

Scarred liver with fibrotic bands

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4
Q

Is Cirrhosis reversible?

A

Traditionally, we thought no. But new treatment options may change outcome and some reversibility. Also, liver transplant.

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5
Q

Describe the pathophysiology behind portal hypertension

A
  1. Increased resistance to portal venous flow (constriction)

2. Increased portal venous blood

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6
Q

What test is STRONGLY suggestive of decompensated cirrhosis/

A

Serum-Ascites Albumin gradient

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7
Q

What is the definition of portal hypertension?

A

Portal venous pressure gradient > 5 mm Hg

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8
Q

What are the most common causes of cirrhosis?

A

Liver disease
Non-cirrhotic portal HTN
Extrahepatic liver disease

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9
Q

What are the most common causes of liver disease?

A
  1. Alcohol
  2. Viral hepatitis (B+C)
  3. Schistosomiasis
    4.
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10
Q

What are common causes of non-cirrhotic portal hypertension?

A

Idiopathic, seen in India/Japan. Usually a vascular coagulopathy.

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11
Q

What are common causes of extrahepatic portal hypertension?

A

Portal vein block caused by tumor/splenomegaly

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12
Q

How do you diagnose portal hypertension?

A

Measure it using either:

  1. Direct catheterization of portal vein
  2. Indirectly with wedged hepatic pressure recording. Transfemoral catheterization of hepatic bein
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13
Q

Are you vasoconstricted or vasodilated in portal hypertension?

A

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
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14
Q

How do you calculate the wedge pressure gradient?

A

Difference between:

1. Wedge minus free hepatic vein pressure

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15
Q

What pathogen can cause portal hypertension?

A

Schistosomiasis: Can cause granulomas to form in the kidney

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16
Q

What would you see as a result of peripheral vasodilation?

A

Well perfused skin

Low BP

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17
Q

What would you see with splanchnic vasodilation?

A

Increased collateral flow/GI permeability=more bacteria

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18
Q

What would you see with increased central vasoconstriction?

A 
Brain dysfunction
Hepatorenal syndrome (decreased renal flow)
Hepatopulmonary syndrome (vasodilation of lungs=hypoxia)
19
Q

What drugs might you use for portal HTN?

A
  1. Beta-blockers=less shear force
  2. alpha-agonist: Treats excessive peripheral vasodilation
  3. anti-inflammatory for liver dz
  4. Surgical shunt
20
Q

What causes a high bleeding risk in pts with liver dz?

A

Esophageal/gastric varices

21
Q

How do you treat varices?

A

Banding sclerotherapy

TIPS divert portal blood flow into the hepatic vein

22
Q

What classification system can you use to characterize liver disease?

A

Child-Pugh gives A/B/C scores

23
Q

What are the components of the child-pugh classification?

A
  1. Ascites
  2. Encephalopathy
  3. Albumin
  4. Bilirubin
  5. PT
24
Q

What’s the difference between a non-selective vs selective shunt?

A

Selective shunts still allow all intestinal flow to go through the liver. Redirects splenic vein.

25
Q

What is your goal in treating PHT?

A

Reduce portal pressure < 12 mmHg

26
Q

What medical therapy is available for PHT?

A

beta blockers (non-selective)

27
Q

How do you treat a bleeding varices?

A
  1. Resuscitate w/ fluid/somatostatin/intubation
  2. Endoscopy within 12 hrs
  3. If esophageal, use acute banding. If gastric, use TIPS
28
Q

What is the mortality rate from variceal bleeding?

A

30-40%

–Most often, bleeding due to ulcers, not varices

29
Q

Causes of Ascites+peritoneal disease?

A

malignancy/inflammation

30
Q

Causes of ascites sine peritoneal disease?

A

Liver dz/vascular blockage

OR hypoalbuminemia

31
Q

What are causes of ascites from parenchymal liver dz?

A
  1. decompensated cirrhosis
  2. alcoholic hepatitis
  3. drugs/herbs
32
Q

Describe the pathophysiology behind PHT/ascites

A
  1. cirrhosis
  2. hypoalbuminemia
  3. 3rd space fluid
  4. Intravascular volume depletion
  5. RAAS activation
  6. Retention of water and salt
33
Q

Describe the secondary process contributing to ascites

A

Vasoconstriction of renal vessels=water/salt retention
AND
systemic/splanchnic vasodilation=volume expansion

34
Q

What lab values would you see in hepatorenal syndrome?

A

HIGH aldo
High renin
Low urine Na
Low creatinine clerance

35
Q

What tests would you run on diagnostic paracentesis?

A

albumin, WBC + diff, Total protein. Consider gram stain/culture, bilirubin, Hgb

36
Q

When should you get a diagnostic paracentesis?

A

In every patient with ascites. Also, get an abdominal CT/US to determine if liver cause.

37
Q

What would cause a high WBC in paracentesis?

A

infection or malignancy

38
Q

What would cause a high TP?

A

infection, malignancy, cardiac failure, hypothyroidism.

39
Q

How would you manage ascites?

A

Spironolcatone
Furosemide
OR
Large volume paracentesis

40
Q

What is the problem with using diuretics in ascites?

A

Can worsen renal failure (hepatorenal syndrome) as well as electrolyte disturbances

41
Q

What is the problem with using high volume paracentesis?

A

Renal failure if draining a TON…if caused by CHF, beneficial. If liver dz, then rapid diuresis can be bad…

42
Q

What are your options in intractable ascites?

A

TIPS or liver transplantation

43
Q

Why are pts with advanced liver disease complicated pts?

A

Pts are in a very fine balance btw vasodilation/constriction. NSAIDS/UTIs can cause renal failure.

GI (27 decks)

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