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3A week 3 - the liver > ascitites + cirrhosis > Flashcards

ascitites + cirrhosis Flashcards

1
Q

what is ascites

A

a localised, pathological collection of fluid within the peritoneal cavity

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2
Q

what are the 3 grades of ascites

A
  1. detectable by imaging only
  2. clinically detectable
  3. tense and obvious (can’t indent abdomen)
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3
Q

causes for abdominal distension (5 Fs)

A

fluid, fat, faeces, foetus, fat

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4
Q
A
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5
Q
A
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6
Q

what is ascites

A

localised, pathological fluid collection within the peritoneal cavity

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7
Q

3 grades of ascites

A
  1. detectable by imaging only
  2. clinically detectable
  3. tense and obvious (can’t indent abdomen)
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8
Q

what are some causes of stomach distension (5 Fs)

A

fluid; fat; faeces; foetus; fat

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9
Q

what is chylothorax

A

a rare but serious condition in which lymph formed in the digestive system (chyle) accumulates in your chest cavity

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10
Q

what is cirrhosis

A

Cirrhosis is permanent architectual change (scarring) of the liver caused by long-term liver damage

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11
Q

fibrosis vs cirrhosis

A

fibrosis can progress and regress due to the activity of stellate cells -> cirrhosis is a permanent change

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12
Q

what equation is used to determine fluid flux into interstitual space between arterioles and venules

A

starling equation

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13
Q

what system drives ascites

A

RAAS

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14
Q

how to work out if ascites is transudative or exudative

A

serum ascites abumen gradient - SAAG

  1. take blood sample
  2. take ascites sample
  3. measure the albumin levels of both
  4. calculate the SAAG (SAAG = (serum albumin) − (albumin level of ascitic fluid))
  5. if >1.1g/DL then transudate
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15
Q

what value must the SAAG be over for ascites to be transudative

A

> 1.1g/Dl

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16
Q

how does hepatic encephalopathy arise

A
  1. astrocyte swelling (build up of toxins not being removed by the liver e.g. ammonia, glutamine, manganese, drugs - benzodiazepines
  2. astrocyte dysfunction (mt. dysfunction, ROS, BBB leakage)
  3. neuronal dysfunction (altered gene expression, decreased Ach etc.)
  4. symptoms of hepatic encephalopathy
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17
Q

what is liverflap (asterixis) associated with

A

hepatic enceophalopathy -> occurs due to build up of toxins in the brain as liver can’t filter them

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18
Q

what is the new haven grading system (hepatic encephalopathy)

A
  1. Changes in behavior with minimal change in level of consciousness;
  2. Gross disorientation, drowsiness, possibly asterixis, inappropriate behavior;
  3. Marked confusion, incoherent speech, sleeping most of the time but arousable to vocal stimuli;
  4. Comatose, unresponsive to pain; decorticate or decerebrate posturing
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19
Q

causes of ascites

A
  1. liver disease - cirrhosis -> transudate
  2. heart failure (esp R side) -> transudate
  3. cancer -> exudate
    4.
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20
Q

causes of cirrhosis

A
  1. alcohol
  2. hep C
  3. NAFLD
  4. primary cholangitis
  5. wilson’s disease (Cu metabolic disorder)
  6. haemochromatosis (Fe metabolic disorder)
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21
Q

what cardiac condition can cause hepatomegaly

A

cor pulmonale (R sided heart englargement due to lung/pulmonary pathology)

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22
Q

when is SAAG very high

A

in causes where there is a rise in sinusoidal/postsinusoidal pressure

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23
Q

if SAAG level is 1.1-2.5g/dL what is the likely cause (3)

A

portal hypertension causes
1. cirrhosis
2. late budd-chiari syndrome
3. massive liver metastases

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24
Q

if SAAG level is >2.5g/dL what is the likley cause (5)

A

post hepatic causes
1. congestive heart failure
2. constrictive pericarditis
3. early budd-chiari syndrome
4. IVC obstruction
5. sinusoidal obstruction syndrome

25
Q

if SAAG level is <1.1g/dL what is the likley cause (5)

A

non portal hypertension cause
1. biliary leak
2. nephrotic syndrome
3. pancreatitis
4. peritoneal carcinomatosis
5. tuberculosis

26
Q

what is ascitic fluid tested for in the lab (7)

A
  1. ascitic albumin
  2. ascitis cytology
  3. ascitic fluid cell count and culture
  4. triglycerides (if >200mg/dL then thought to be chylous)
  5. amylase
  6. bilirubin
  7. adenine deaminase (if thought to be TB)
27
Q

causes of prehepatic portal vein hypertension (3)

A
  1. portal vein thrombosis
  2. splenic vein thrombosis
  3. massive splenomegaly
28
Q

causes of hepatic portal vein hypertension (5)

A

presinusoidal
1. schistosomiasis
2. congenital hepatic fibrosis
sinusoidal
3. cirrhosis
4. alcoholic hepatitis
postsinusoidal
5. hepatic veno-occlusive disease

29
Q

causes of post-hepatic portal vein hypertension (4)

A
  1. budd-chiari syndrome
  2. restrictive cardio myopathy
  3. constrictive pericarditis
  4. congestive heart failure
30
Q

what is budd-chiari syndrome

A

an uncommon disorder characterized by obstruction of hepatic venous outflow - can be thrombotic or non-thrombotic -> portal hypertension

31
Q

causes of inflammatory (non portal vein) hypertension (6)

A
  1. radiation
  2. pancreatitis
  3. retroperitoneal fibrosis
  4. sarcoidosis
  5. whipple’s disease
32
Q

causes of post-operative (non portal vein) hypertension (4)

A
  1. AAA repair
  2. post-liver transplant
  3. retroperitoneal node dissection
  4. inferior vena cava resection
33
Q

what is the main cause of ascites

A

cirrhosis

34
Q

what does the presence of ascites indicate in a cirrhotic pt

A

marks decompensation (along with other signs e.g. jaundice etc.)

35
Q

signs of liver decompensation (6)

A
  1. ascites
  2. jaundice
  3. variceal bleeding
  4. liver encephalopathy
  5. falling albumen
  6. coagulopathy
36
Q

what is an ascitic pt at risk of

A

ascititc infection (sponatenous bacterial peritonitis)

37
Q

what are the categories in the childs-pugh score (5)

A
  1. eceophalopathy
  2. ascites
  3. bilirubin (high is bad - >3 severe)
  4. albumin (low is bad - <2.8 severe)
  5. prothrombin time (>2.3 is severe)
38
Q

in a normal liver is there a pressure gradient across the liver

A

no

39
Q

when can it be said that portal hypertension is present

A

(Inferior Vena Cava pressure) - Portal Vein pressure <5mmHg
i.e. there is an increased gradient across the liver

40
Q

what are the 3 blood supplies of the liver

A
  1. hepatic artery
  2. portal vein
  3. hepatic vein
41
Q

why can the portal vein pressure increase

A
  1. more blood flow coming in
  2. block to flow (resistance)

pressure = resistance x flow

42
Q

3 types of portal hypertension

A
  1. pre heptic
  2. hepatic
  3. post hepatic
43
Q

variceal haemorrhage treatment

A

surgery - rubber bands to stop bleeding and allow for fibrosis of bleeding point

44
Q

causes of increased resistance in portal hypertension (4)

A

early
1. cellular elements
2. organ contraction
late
3. scar (fibrosis)
4.nodules

45
Q

3 complications of cirrhosis

A
  1. hepatocellular carcinoma
  2. immune system paresis (liver is v important for innate immune system)
  3. decompensation event
46
Q

what is the arterial underfilling hypothesis (ascites)

A

the primary abnormality is inappropriate sequestration of fluid within the splanchnic vascular bed due to portal hypertension and a consequent decrease in effective circulating blood volume

47
Q

arterial underfilling hypothesis (ascites) steps (8)

A
  1. increased intrahepatic resistance
  2. increased mesenteric blood flow
  3. portal pressure goes up
  4. reduced intrathoracic blood volume
  5. activation of vasoconstrictor mechanisms (NA, ADH, RAAS)
  6. retention of salt and water at kidney level
  7. increased venous pressure at capillaries of mesenteric system
  8. intraperitoneal accumulation of fluid

i.e. decreased blood intrathroacically leads to vasoconstriction and retention of water -> increased capillary pressure and accumulation of fluid

48
Q

ascites mgx

A

diuretics - spironolactone/frusemide

no added salt

49
Q

if ascites is diuretic resistant/patients cant tolerate them what is the mgx

A

large volume paracentesis - US guided drain of the fluid

50
Q

what must be given to pt undergoing large volume paracentesis (ascites)

A

albumin - 2.5 L

51
Q

why is large volume paracentesis only left in for 6hrs max

A

risk of infection

52
Q

what is a TIPS shunt and when is it used (GI)

A

Transjugular intrahepatic portosystemic shunt - a procedure that involves inserting a stent (tube) to connect the portal veins to adjacent blood vessels that have lower pressure thus relieving pressure

used in ascites

53
Q

what is a complication of ascites

A

spontaneous bacterial peritonitis

54
Q

secondary prophylaxis for spontaneous bacterial peritonitis

A

Rifaximin

55
Q

primary prophylaxis for spontaneous bacterial peritonitis

A

norfloxican - given if childs-pugh score is >9

56
Q

what is AKI-HRS

A

Acute kidney injury and hepatorenal syndrome in cirrhosis -> a severe and often fatal complication of end‐stage liver disease

57
Q

treatment of Hepato-renal syndrome

A
  1. volume expansion - albumin
  2. vasoconstrictors - (midodrine + octerotide) or NA/ADH/terlipressin
  3. dialysis - only if liver failure is reversible or the pt is a liver transplant candidate
58
Q

oesophageal varices bleed mgx

A

medical emergency:
1. intravascular volume support -> IV fluids
2. blood transfusion (with the aim of keeping the haemoglobin around 70-80 g/L [7-8 g/dL])
3. Terlipressin (a vasopressin analogue), or somatostatin (or its analogue octreotide) should be initiated as soon as a variceal bleed is suspected
4. endoscopy -> Endoscopic variceal ligation or sclerotherapy
5. abx - ceftriaxone is cirrhosis

if bleed so large can’t be stopped by EVL, use a Sengstaken-Blakemore tube or a Danis stent until haemostasis is achieved

3A week 3 - the liver (9 decks)

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