Chronic liver failure Flashcards
What histologic changes are seen in cirrhosis?
characterized by the development of fibrous septa surrounding regenerating hepatocellular nodules
What is the definition of portal pressure gradient?
difference in pressure between the portal vein and the hepatic veins
What is the definition of portal HTN?
portal pressure gradient > 5 mm Hg
How is portal pressure gradient measured?
by transfemoral-hepatic vein catheterization with a balloon tip catheter
What is the most common cause of prehepatic portal hypertension?
portal vein thrombosis
-up to 50% of portal HTN in pediatrics
What is the most common cause of intrahepatic presinusoidal hypertension?
schistosomiasis
-also many causes of nonalcoholic cirrhosis result in presinusoidal portal HTN
What is the most common cause of portal HTN in the United States?
alcoholic cirrhosis
-at sinusoidal level is d/t increased resistance to portal flow at the sinusoidal 2/2 to deposition of collagen in the space of Disse
-at postsinusoidal level is 2/2 regenerating nodules distorting small hepatic veins
What are cases of posthepatic or postsinusoidal causes of portal hypertension?
rare entity
-Budd-Chiari syndrome (hepatic vein thrombosis)
-constrictive pericarditis
-heart failure
What are the components of Child-Turcotte-Pugh score?
-bilirubin
-serum albumin
-prothrombin time
-ascites
-encephalopathy
What are the chances of mortality after major abdominal surgery in a pt w/ CTP grade A?
no additional risk
What are the chances of survival after major abdominal surgery in a pt w/ CTP grade B?
81%
What are the chances of survival after major abdominal surgery in a pt w/ CTP grade C?
45%
What are the components of MELD score?
-INR
-creatinine
-bilirubin
-now Na too
What ammonia level is consistent w/ hepatic encephalopathy?
> 60mcg/dL
What medical treatments should be used for hepatic encephalopathy?
-haloperidol for agitation and avoid benzos
-lactulose to decrease ammonia absorption from the GI tract
-rifaximin or neomycin to prevent production of ammonia by gut bacteria
What are systemic effects of cirrhosis that lead to relative hypotension and low SVR?
-indiscriminate dilation of the splanchnic vascular beds
-low albumin levels
-those two combined can lead to profound loss of fluids into 3rd spaces and intravascular hypovolemia
What medication can be used to help w/ the splanchnic vascular dilation that leads to hypotension in cirrhosis?
midodrine for pts who can take PO
What consequences of cirrhosis increase a patient’s risk of aspiration?
-abd distention
-autonomic dysfunction of GI motility
-AMS
-frequent use of PPIs
What is the definition of hepatopulmonary syndrome?
SOB and hypoxemia caused by vasodilation in the lungs of pts w/ liver disease
-inefficient distribution of blood through lung and subsequent pulmonary vascular dilation causing shunting leading to treatment resistant hypoxemia
For respiratory support should mechanical ventilation or noninvasive be utilized?
mechanical ventilation
-hepatic encephalopathy w/ impaired GI motility and increased intra-abd pressure makes aspiration a danger
What is the survival rate of a patient w/ hepatorenal syndrome who does not undergo transplant at 1 month? At 6 months?
-50%
-20%
What is type 1 hepatorenal syndrome? Type 2 hepatorenal syndrome?
-type 1 = sudden onset w/ doubling of serum creatinine to > 2.5 in less than 2 weeks from onset
-type 2 = more chronic
What is the definition of hepatorenal syndrome?
acute doubling of serum creatinine without other cause in pt w/ severe liver disease
What are the hallmark laboratory values seen in hepatorenal syndrome?
-elevated serum creatinine (at least doubles)
-severely low urine sodium
