Chronic Liver Disease - part 2 Flashcards
What does Right sided Heart Failure cause in the liver?
Passive congestion (nutmeg liver)
What labs will be elevated with Right sided Heart Failure that is affecting the liver?
Increased AST/ALT
Really INCREASED BNP
What is Ischemic Hepatitis?
“Shock liver” - hypoxic hepatitis due to fall in cardiac output (ex. MI)
What may protect against Ischemic Hepatitis?
Statin therapy
What labs will be elevated with Ischemic Hepatitis?
SUPER ELEVATED AST/ALT > 5000
Increased LDH
What sign will be present with the liver and heart failure?
Hepatojugular reflux
Cirrhosis is a complication of many liver disease. List the 3 most common.
Alcohol-Induced Liver Injury
NAFLD
Hepatitis C
How does Cirrhosis arise?
- Liver injury
- Inflammation
= Fibrosis and regenerative nodules
What is the usually in the history with Cirrhosis?
Jaundice
Ascites - look pregnant
Encephalopathy - confusion
With Cirrhosis the physical exam shows the stigmata of Cirrhosis. The physical exam can be normal until?
End stage
List abdominal changes with Cirrhosis
Ascites
Caput medusae (abdominal vein dilation)
Umbilical hernia
List skin changes with Cirrhosis
Jaundice
Spider Angiomata (telangiectasias)
Gynecomastia in males
List hand/wrist changes with Cirrhosis
Asterixis
Dupuytren’s contracture
Nail changes
What causes the nail changes that are seen with Cirrhosis?
HYPOalbuminemia
List esophagus and mental changes with Cirrhosis
Esophageal varices
Vitamin deficiencies
Mental status changes
What are possible complications of Cirrhosis?
Hepatocellular carcinoma
Portal HTN - Ascites, variceal bleeding, SBP
With Cirrhosis what should you treat?
Underlying cause
With Cirrhosis, it can cause Hepatocellular carincoma, so you should monitor?
Alpha Fetoprotein (AFP) and US every 6 months
2 prognoses for Cirrhosis that are important for the transplant list?
- Child - Turcotte - Pugh Score
- MELD
What scores for the Child-Turcotte-Pugh score with Cirrhosis are severe?
C
> 7
What scores for the MELD are severe with Cirrhosis?
> 10-14
SAAG
Serum Albumin - Ascites Albumin
Ascites can either be?
Portal HTN
Non-portal HTN
SAAG > ____ is portal HTN Ascites
1.1
SAAG < ____ is non-portal HTN Ascites
1.1
Portal HTN Ascites likely causes?
Cirrhosis
CHF
Budd-Chiari Syndrome
Ascites
Accumulation of fluid in peritoneal cavity
Most common cause of Ascites?
Cirrhosis (portal HTN)
What will be seen on physical exam with Ascites?
Increasing abdominal girth, larger tender liver
(+) shifting dullness
What will an Abdominal US show with Ascites?
Fluid
When should an Abdominal paracentesis be performed with an Ascites patient?
- new onset ascites
- pts admitted to hospital for ascites
- when ascites pts start to deteriorate
What is the most important test to run on the Ascites fluid and why?
WBC
- PMN>250 == SBP
SBP
Spontaneous (primary) Bacterial Peritonitis
SBP is most common in patients with?
Cirrhosis
What causes SBP?
Hematogenous spread of organisms to ascitic fluid because the liver cannot filter them
Is a single organism usually isolated with SBP?
Yes - e. coli/cocci
Signs of SBP?
Fever, Abdominal pain and signs of peritoneal irritation
- OR nonspecific manifestations
PMN > _____ in peritoneal fluid classifies SBP
250
What else should you perform on the peritoneal fluid with SBP besides WBC check?
Blood cultures because bacteremia is common
What is the treatment for SBP?
Empirical antibiotic treatment
Hepatic Encephalopathy
Alteration in mental status in presence of liver failure
- neurotoxins are not removed by the liver
What will be increased with Hepatic Encephalopathy?
Ammonia
What are a few precipitants to Hepatic Encephalopathy?
GI bleed
Constipation
Sepsis
What is the treatment for Hepatic Encephalopathy?
Lactulose - causes diarrhea
- Remove precipitants and correct electrolytes
What are the grades for Hepatic Encephalopathy?
1 - mild confusion
2 - drowsy
3 - stupor
4 - coma
Who is at risk for Hepatocellular carcinoma?
Males with cirrhosis
What will be increased with Hepatocellular carincoma?
Alpha Fetoprotein (AFP)
In patients with known liver disease, you should screen for hepatocellular carcinoma.. how?
AFP and abdominal US every 6 months
In patients with known liver disease, you should screen for hepatocellular carcinoma.. how?
AFP and abdominal US every 6 months
What is the treatment for Hepatocellular carcinoma?
Surgery, ablation, liver transplant
