Ascites and portal hypertension Flashcards
What are the complications of cirrhosis ?
portal hypertension=>variceal haemorrhage and ascites=>SBP and HRS
liver insufficiency =>jaundice and encephalopathy
hepatocellular carcinoma
What is ascites?
fluid within the peritoneal cavity “abdominal dropsy”, “hydroperitoneum’
What are the causes of ascites?
malignancy portal hypertension heart failure (inc constrictive pericarditis) nephrotic syndrome infection
What are the symptoms of ascites?
pain and discomfort
morphological change and weight gain
breathlessness
What physiological changes does ascites cause?
vasodilatation and reduced effective circulation volume
RAS activation and salt retention
portal hypertension and hydrostatic pressure
increased capillary permeability
lymph formation>return
hyperdynamic circulation
What is SAAG?
Serum albumin-ascitic albumin concentration
= serum albumin - ascitic fluid albumin
What does a high gradient SAAG mean?
> 1.1g/dL = predicts ascites due to PH with 97% accuracy
- high protein (>2.5g/dL): heart failure budd chiari syndrome
- low protein (<2.5g/dl): cirrhosis of the liver, nephrotic syndrome
transudate - low protein state
What does a low gradient SAAG mean?
<1.1g/dl = cause is not due to PH
-Infection, cancer or inflammation
exudate - high protein state
Why is salt restriction necessary in portal hypertension/ascites?
sodium retained iso-osmotically in kidney
10-15% of pts lose ascites with salt restriction alone
How effective is diuretic therapy for ascites and what are the complications?
diuretics effective in treating up to80-90% pts with ascites
absence of renal dysfunction up to 95% of pts respond to diuretics alone
remaining pts either fail to respond or become intolerant of diuretic induced SE
complications
- 20% renal dysfunction
- 20% hyponatraemia
- 25% encephalopathy
- other: muscle cramps, electrolyte disturbance, anti-androgenic SE of spironolactone metabolites
Where do loop diuretics and aldosterone competitors work?
loop diuretics = furosemid/bumetanide
- act on NaK2Cl in the loop on henle
aldosterone competitors - spironolactone / canrenoate act on NaK atpase in the DCT
What is cirulatory dysfunction following paracentesis dependent upon?
volume drained and colloid replacement used
Why does spontaneous bacterial peritonitis occur?
increased bowel permeability
jejunal overgrowth and floral change
reduced innate immunity (TLR, inflammasone, complement, antibodies)
What reduces the incidence ofSBP?
abx prophylaxis
What is the purpose of TIPS?
To divert blood away from liver to reduce portal pressure
