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Hepatic > Chronic liver failure > Flashcards

Chronic liver failure Flashcards

1
Q

What histologic changes are seen in cirrhosis?

A

characterized by the development of fibrous septa surrounding regenerating hepatocellular nodules

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2
Q

What is the definition of portal pressure gradient?

A

difference in pressure between the portal vein and the hepatic veins

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3
Q

What is the definition of portal HTN?

A

portal pressure gradient > 5 mm Hg

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4
Q

How is portal pressure gradient measured?

A

by transfemoral-hepatic vein catheterization with a balloon tip catheter

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5
Q

What is the most common cause of prehepatic portal hypertension?

A

portal vein thrombosis
-up to 50% of portal HTN in pediatrics

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6
Q

What is the most common cause of intrahepatic presinusoidal hypertension?

A

schistosomiasis
-also many causes of nonalcoholic cirrhosis result in presinusoidal portal HTN

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7
Q

What is the most common cause of portal HTN in the United States?

A

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

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8
Q

What are cases of posthepatic or postsinusoidal causes of portal hypertension?

A

rare entity
-Budd-Chiari syndrome (hepatic vein thrombosis)
-constrictive pericarditis
-heart failure

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9
Q

What are the components of Child-Turcotte-Pugh score?

A

-bilirubin
-serum albumin
-prothrombin time
-ascites
-encephalopathy

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10
Q

What are the chances of mortality after major abdominal surgery in a pt w/ CTP grade A?

A

no additional risk

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11
Q

What are the chances of survival after major abdominal surgery in a pt w/ CTP grade B?

A

81%

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12
Q

What are the chances of survival after major abdominal surgery in a pt w/ CTP grade C?

A

45%

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13
Q

What are the components of MELD score?

A

-INR
-creatinine
-bilirubin
-now Na too

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14
Q

What ammonia level is consistent w/ hepatic encephalopathy?

A

> 60mcg/dL

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15
Q

What medical treatments should be used for hepatic encephalopathy?

A

-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

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16
Q

What are systemic effects of cirrhosis that lead to relative hypotension and low SVR?

A

-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

17
Q

What medication can be used to help w/ the splanchnic vascular dilation that leads to hypotension in cirrhosis?

A

midodrine for pts who can take PO

18
Q

What consequences of cirrhosis increase a patient’s risk of aspiration?

A

-abd distention
-autonomic dysfunction of GI motility
-AMS
-frequent use of PPIs

19
Q

What is the definition of hepatopulmonary syndrome?

A

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

20
Q

For respiratory support should mechanical ventilation or noninvasive be utilized?

A

mechanical ventilation
-hepatic encephalopathy w/ impaired GI motility and increased intra-abd pressure makes aspiration a danger

21
Q

What is the survival rate of a patient w/ hepatorenal syndrome who does not undergo transplant at 1 month? At 6 months?

A

-50%
-20%

22
Q

What is type 1 hepatorenal syndrome? Type 2 hepatorenal syndrome?

A

-type 1 = sudden onset w/ doubling of serum creatinine to > 2.5 in less than 2 weeks from onset
-type 2 = more chronic

23
Q

What is the definition of hepatorenal syndrome?

A

acute doubling of serum creatinine without other cause in pt w/ severe liver disease

24
Q

What are the hallmark laboratory values seen in hepatorenal syndrome?

A

-elevated serum creatinine (at least doubles)
-severely low urine sodium

25
Q

For chronic liver failure how is their position on the waiting list determined?

A

by the local procurement organization

26
Q

What is the Milan criteria for transplant in pts w/ HCC?

A

-single tumor < 5cm
-up to 3 tumors < 3cm
-absence of macroscopic vascular invasion
-absence of extrahepatic spread

27
Q

What are the components of initial management of bleeding esophageal varices?

A

-airway management
-fluid resuscitation
-coagulation stabilization
-prophylactic antibiotics
-octreotide
-PPI therapy

28
Q

What is the optimal prophylaxis strategy to prevent rebleeding of esophageal varices?

A

-non-selective beta blocker (propranolol) to reduce portal venous pressure
-alcohol cessation to stop progression of disease and reduce inflammation
-endoscopic variceal ligation every 1-2 weeks until all varices have been removed
-regular EGD q3-6 months after

this combination has lowest rebleeding rate of 15%

29
Q

What is the test of choice to diagnose hepatopulmonary syndrome?

A

contrast echocardiogram w/ agitated saline contrast

30
Q

How is hepatopulmonary syndrome defined?

A

-hypoxemia
-dyspnea
-othodeoxia (worsening O2 sats w/ standing)
-platypnea (worsening SOB w/ sitting or standing that improves w/ lying down)
-intrapulmonary vasodilation

all in the presence of cirrhosis and portal HTN

31
Q

What alveolar-arterial gradient is suggestive of hepatopulmonary syndrome?

A

-in adults > 15mmHg
-in geriatric pts > 20mmHg

while seated

32
Q

What is the treatment for hepatopulmonary syndrome?

A

supportive w/ O2 support (+/- positive pressure ventilation) until able to undergo hepatic transplant

33
Q

What are absolute contraindications of liver transplant?

A

-PaO2 < 50mm (or other evidence of cardiopulmonary failure)
-extrahepatic malignancy
-acute alcohol or substance abuse
-active, uncontrolled viremia

34
Q

What are some relative contraindications for liver transplant?

A

-advanced age
-AIDS
-cholangiocarcinoma
-diffuse portal vein thrombosis

Hepatic (3 decks)

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