Cirrhosis Flashcards
What is Cirrhosis? (4 things)
- Irreversible damage
- Loss of normal hepatic architecture
- Fibrosis
- Nodules
What are the most common causes of Cirrhosis? (4 things)
- ALD
- NAFLD
- Hepatitis B
- Hepatitis C
What are the CF of Cirrhosis? (14 things)
- Alopecia
- Fatigue
- Lethargy + Confusion + Coma (bc hepatic encephalopathy)
- Jaundice
- Upper GI bleeding (bc portal HTN –> oesophageal varices)
- Asterixis (hand flap) (bc hepatic encephalopathy)
- Palmar erythema (red palms)
- Clubbed nails
- Leuconychia (white nails) (bc hypoalbuminaemia)
- Dupuytren’s Contracture (flexion deformity of fingers bc thickening + shortening of palmar fascia)
- Pruritis (bc salt deposition in skin)
- Caput medusae (periumbilical vein dilation)
- Ascites (bc portal HTN + low albumin)
- Weight loss
- Hyperoestrogenism (gynecomastia / erectile dysf / infertility)
(Head to toe)
What tests should be done for sus Cirrhosis? (5 things)
- Bloods
- Liver US / FibroScan
- CT / MRI
- Liver biopsy
- Endoscopy
What bloods should be done for sus Cirrhosis? (3 things)
- LFTs
- FBC
- Autoantibodies
What will be seen in the LFTs of Cirrhosis? (2 things)
- Everything raised
2. Reduced albumin
What will be seen in a FBC of Cirrhosis? (2 things)
- Low WBCC
2. Low platelets (earliest finding)
What do the low WBCC and platelets in Cirrhosis indicate?
Hypersplenism
What does checking for Autoantibodies in bloods of Cirrhosis tell you?
The cause of Cirrhosis
What may a Liver US show in Cirrhosis? (7 things)
- Hepatomegaly / small liver (late disease)
- Splenomegaly
- Nodules on liver surface
- Hepatic vein thrombus
- Enlarged portal vein w REDUCED flow
- “Corkscrew” appearance of arteries w INCREASED flow
- Ascites
Why do the arteries in liver have INCREASED flow in Cirrhosis?
To compensate for reduced portal flow
What is a FibroScan US used for in Cirrhosis?
Checks elasticity of liver, so assesses degree of Cirrhosis
What are you looking for in CT / MRI for Cirrhosis? (6 things)
- Hepatocellular Carcinoma
- Hepatosplenomgaly
- Abn blood vessel changes / varices
- Ascites
- Increased caudate lobe size
- Nodules
What is a Liver biopsy used for in sus Cirrhosis?
Confirms clinical diagnosis
When should an Endoscopy be done in Cirrhosis?
When sus Portal HTN
What is an Endoscopy used for in Cirrhosis?
Assess + Treat oesophageal varices (caused by portal HTN)
What is the General management for Cirrhosis? (5 things)
- MANAGE COMPLICATIONS
- US + alpha-fetoprotein every 6 months for Hepatocellular Carcinoma
- Endoscopy every 3 yrs (in pt w/o varices)
- MELD score every 6 months
- High protein, Low sodium diet
What is the score used in Cirrhosis to see if a patient needs a liver transplant?
MELD Score
What does the MELD Score take into account? (5 things)
- Bilirubin
- Dialysis - Do they need dialysis?
- INR
- Creatinine
- Sodium
B DICS
What medications should be avoided in Cirrhosis? (3 things)
- NSAIDs
- Sedatives
- Opiates
What are the complications of Cirrhosis? (6 things)
- Hepatic Failure
- Portal HTN –> Varices + Variceal Bleeding
- Malnutrition / Muscle wasting
- Hepatorenal Syndrome
- Hepatic Encephalopathy
- Hepatocellular Carcinoma
What are the CF of Hepatic Failure (complication of Cirrhosis)? (5 things)
- Coagulopathy (failure of hepatic synth of clothing factors)
- Hepatic encephalopathy
- Oedema (hypoalbuminaemia)
- Sepsis (pneumonia / septicaemia)
- Hypoglycaemia
What are the CF of Portal HTN (complication of Cirrhosis)? (4 things)
- Oesophageal varices
- Splenomegaly
- Ascites
- Caput medusae (periumbilical vein dilation)
Where does the Portal Vein come from? (2 things)
- Superior mesenteric vein
2. Splenic vein
Where does the Portal Vein deliver blood to?
Liver
How does Portal HTN cause Varices in Cirrhosis? (4 steps)
- Fibrosis affects blood flow thru liver
- This increases resistance of blood flow in liver
- Increased back-pressure into Portal System –> Portal HTN
- Vessels where Portal System anastomoses w Systemic Venous System become Swollen = Varices
Where do Varices in Cirrhosis occur? (4 locations)
- Gastro-Oesophageal junction
- Anterior abd wall via umbilical vein (Caput Medusae)
- Ileocaecal junction
- Rectum
When do Varices cause symptoms or problems?
Only when they start bleeding, which is common bc high blood flow thru them
What are the treatment options for Stable Varices in Cirrhosis? (4 things)
- Propranolol (reduced Portal HTN)
- Elastic band ligation of Varices
- Injection of Sclerosant (less effective than band ligation)
- Transjugular Intra-Hepatic Portosystemic Shunt (TIPS) (done by interv. radiologist)
How should a pt w bleeding Oesophageal Varices be managed? (2 things)
- Resus
2. Urgent endoscopy
How should a pt w bleeding Oesophageal Varices be Resuscitated? (4 things)
- Vasopressin analogies (cause vasoconstriction –> slow bleeding)
- Vit K + Fresh Frozen Plasma (correct coagulopathy)
- Prophylactic Broad spec Abx
- Consider intubation / ICU
What is done in Urgent Endoscopy of bleeding Oesophageal Varices in Cirrhosis? (2 things)
- Sclerosant injected (causes inflammatory obliteration of vessel)
- Elastic band ligation
How does Ascites happen in Cirrhosis? (2 steps)
- Increased pressure in Portal System
2. Fluid leaks out of capillaries in liver + bowel –> Peritoneal Cavity
How does Ascites from Cirrhosis affect the kidney? (5 steps)
- Fluid loss into Peritoneal cavity –> drop in circulating volume
- Drop in circulating volume –> reduction in BP entering kidneys
- Kidney sense low BP –> release Renin
- Renin –> causes Aldosterone secretion (via RAAS system)
- Renin –> reabsorbtion of fluid + Na in kidneys
How should Ascites from Cirrhosis be managed? (5 things)
- Low sodium diet
- Diuretics (e.g spironolactone) (to oppose aldosterone)
- Paracentesis (drain fluid)
- Prophylactic abx (vs Spontaneous Bacterial Peritonitis)
- Consider TIPS / transplant
What is Spontaneous Bacterial Peritonitis?
Infection dev in Ascites fluid + Peritoneal lining
What are the CF of Spontaneous Bacterial Peritonitis? (6 things)
- Can be asymptomatic
- Fever
- Abd pain
- Deranged bloods (raised WBC, CRP, Creatinine)
- Ileus (lack of movement in intestines)
- Hypotension
What is the most common organism that causes Spontaneous Bacterial Peritonitis?
E. coli
How is Spontaneous Bacterial Peritonitis managed? (2 things)
- Take ascitic culture before abx
2. IV cephalosporin
Why does Malnutrition / Muscle wasting happen in Cirrhosis? (2 steps)
- Cirrhosis –> reduces protein available / synth.
2. Body uses muscle tissue as fuel
How does Cirrhosis lead to reduced protein available? (2 things)
- Reduced protein produced in liver
2. Reduced protein available for muscle growth
Why does the body use muscle tissue as fuel in Cirrhosis?
Cirrhosis disrupts the ability for liver to store glucose as Glycogen and release it when needed
What is the management of Malnutrition / muscle wasting in Cirrhosis? (4 things)
- Reg meals (every 2-3 hrs)
- Low sodium diet (to min. fluid retention)
- High prot + calories
- Avoid alcohol
How does Hepatorenal Syndrome happen in Cirrhosis? (8 steps)
- Increased pressure in Portal System
- Fluid leaks out of capillaries in liver + bowel –> Peritoneal Cavity
- Fluid loss into Peritoneal cavity –> drop in circulating volume
- Drop in circulating volume –> reduction in BP entering kidneys
- Kidney sense low BP –> release Renin –> activates RAAS system
- RAAS system –> Renal vasoconstriction
- Renal vasoconstriction + low circ volume = blood starvation of kidney
- Leads to rapidly deteriorating kidney
How long does it take for Hepatorenal Syndrome to kill you?
1 week
What is the treatment for Hepatorenal Syndrome?
Liver transplant
How does Cirrhosis cause Hepatic Encephalopathy?
Cirrhosis causes ammonia build up –> ammonia = toxin that affects brain
Why does Ammonia build up in Cirrhosis? (2 things)
- Functional impairment of liver cells –> X metabolise ammonia into harmless waste products
- Collateral vessels between Portal n Systemic circ –> ammonia bypasses liver –> ammonia enters systemic system directly
What are the precipitating factors for Hepatic Encephalopathy? (6 things)
- Constipation
- Elec imb
- Infection
- GI bleed
- High prot diet
- Sedative meds
What are the CF of Hepatic Encephalopathy? (6 things)
- Confusion + Coma
- Drowsiness
- Fetor hepaticus (stanky breath)
- Hyperventilation
- Asterexis
- Changes in personality n memory n mood (CHRONICALLY)
How should you manage a pt with Hepatic Encephalopathy? (3 things)
- Laxatives (e.g lactulose) (to promote ammonia excretion)
- Abx (e.g rifaximin) (reduces number of intestinal bac producing ammonia)
- Nutritional support (may need NG feeding)
