Cirrhosis Flashcards

1
Q

What is the portal venous system?

A

● Blood drains into the portal system from stomach, spleen, and intestines (detoxification, nutrient storage in liver)

● Blood then goes to systemic circulation via inferior vena cava (IVC)

● Cirrhosis causes a back-up of blood in the portal system (blood can’t go through liver easily; ↑portal pressure)

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2
Q

What are the major functions of the liver?

A

Purification, transformation and clearance of:
toxins
drugs
hormones

Regulation of:
glucose cholesterol

Metabolism of:
carbohydrates
fats
amino acids

Synthesis and secretion of: clotting factors transporter proteins cholesterol
bile for digestion glucose

Regenerative organ

Storage of:
glucose
fat-soluble vitamins
folic acid
vitamin B12
iron
copper

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3
Q

What are the hepatic lobules?

A

helps flow of material

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4
Q

What is Cirrhosis?

A

impaired liver function caused by formation of tissue (fibrosis) due to damage by liver disease

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5
Q

How does Cirrhosis happen?

A

Liver damage causes tissue repair and subsequent formation of scar tissue, which over time can replace normal functional tissue leading to impaired liver function

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6
Q

How fast does Cirrhosis occur?

A

Typically develops slowly over months or years (slow, gradual process)

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7
Q

What is Cirrhosis AKA?

A

Also known as liver cirrhosis or hepatic cirrhosis, and end-stage liver disease

Cirrhosis was derived from the Greek word “kirrhos” which describes yellowish color of a diseased liver
stage liver disease

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8
Q

What is Cirrhosis like in the late stage?

A

● Cirrhosis is a late stage of scarring (fibrosis) of liver caused by liver diseases (eg hepatitis, chronic alcoholism)

● Each time liver is injured, it tries to repair itself and in the process scar tissue forms.

● As cirrhosis progresses, more scar tissue forms, making it difficult for liver to function (decompensated cirrhosis)

● The liver damage done by cirrhosis is generally NOT REVERSIBLE and advanced cirrhosis is life-threatening

● If liver cirrhosis is diagnosed early and the cause is treated, further damage can be limited and rarely reversed

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9
Q

What is the pathogenesis of cirrhosis?

A

balance is lost - therefore more fibrogenesis in scar tissue

  • Ascites - heavy & puts pressure of heart & lungs (poor QOL)
  • Liver nodules - regenerative nodules
    – normal structure is lost & BF is lost
    – diff sizes of nodules in the liver
    – not normal structure (shape diff)
  • Fibrosis - blue areas => sign amount of scar tissue formation
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10
Q

What is the major risk factors?

A

● Excessive alcohol consumption (esp during chronic periods long term)

● Being overweight
- obesity increases risk of conditions that may lead to cirrhosis (eg non-alcoholic fatty liver disease)
- build up of fat in liver increases

● Chronic viral hepatitis
- it is one of the world’s leading causes of liver disease
- NOT everyone with chronic hepatitis develops cirrhosis

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11
Q

What are the common causes of cirrhosis?

A

A wide range of diseases and conditions can damage the liver and lead to cirrhosis
● chronic viral HEPATITIS (B, C, D)
● chronic ALCOHOL ABUSE
● non-alcoholic FATTY LIVER DISEASE (fat accumulation in liver)
● DRUGS and HERBALS
● METABOLIC LIVER DISEASE
- hemochromatosis (iron build up in body)
- Wilson’s disease (copper accumulated in liver)
- alpha-1 antitrypsin deficiency

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12
Q

What are the signs & symptoms of cirrhosis?

A

● EARLY stages Asymptomatic
● fatigue, anorexia, weight loss, nausea
● hepatomegaly, splenomegaly
● ascites, edema (legs, ankles), pleural infusion
● easily bleeding or bruising
● pruritus (itchy skin), jaundice, dark urine
● palmar erythema, spider angiomata (spiderlike blood
vessels on skin
● FEMALES: absent or loss of periods
● MALES: reduced libido (loss of sex drive), gynecomastia
(breast enlargement), testicular atrophy
● hepatic encephalopathy (confusion, drowsiness, slurred
speech )

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13
Q

What are some signs/symptoms of cirrhosis?

A
  • spider angiomata
  • asterixis
  • palmar erythema
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14
Q

What are the signs & symptoms of cirrhosis?

A

● Cirrhosis *can take a long time to develop

● Cirrhosis often has no signs or symptoms until liver damage is extensive

● *Patients with cirrhosis have higher risk of liver cancer

● *Liver size can be enlarged, normal, or shrunken in people with cirrhosis

● As the disease progresses, liver size typically shrinks due to scar formation

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15
Q

What are the complications of cirrhosis?

A
  • Portal hypertension
  • Swelling in legs and abdomen
  • Enlargement of spleen (splenomegaly)
  • Bleeding. Portal hypertension may cause:
    ● Blood to be redirected to smaller veins, strained by extra
    pressure, smaller veins can burst, cause serious bleeding
    ● Enlarged veins in esophagus or stomach (esophageal or gastric varices), lead to life-threatening bleeding
    ● Inability of liver to produce enough clotting factors can contribute to continued bleeding
  • Jaundice
  • Hepatic encephalopathy (buildup of toxins in brain)
  • Increased risk of liver cancer
  • Infection
  • Acute-on-chronic cirrhosis
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16
Q

What are the most imp. complications of cirrhotic liver?

A
  1. Portal Hypertension*
  2. Ascites*
  3. Variceal bleeding*
  4. Hepatic encephalopathy (buildup of toxins in brain)*
  5. Spontaneous bacterial pertonitis (infection - b/c decrease WBC & therefore increase risk of infection)*
17
Q

What are the Child-Pugh classification system?

A

● A means of quantifying the myriad effects of cirrhotic process on laboratory and clinical manifestations

● Assess and define the severity of the cirrhosis

● A predictor for patient survival, surgical outcome, and
risk of variceal bleeding

● Drug-dosing adjustments for patients in liver failure
- b/c many drugs are metabolized in liver (see how damaged liver is)

● Mayo End-Stage Liver Disease (MELD) scoring system is now the accepted classification scheme used by the United Network for Organ Sharing (UNOS) in the allocation livers for transplantation

18
Q

What is the criteria & scoring for the Child-Pugh grading of chronic liver disease?

A

● By employing the Child-Pugh score, chronic liver diseases are classified into Child–Pugh class A to C

19
Q

What is the grading of hepatic encephalopathy?

A

It’s graded as 0, minimal, 1-4

& there are 4 factors:
1. Level of Consciousness
2. Personality/Intellect
3. Neurologic Abnormalities
4. Electroencephalogram Abnormalities (EEG)

20
Q

How do you diagnose Cirrhosis?

A

Diagnosis is based on BLOOD TESTS, medical IMAGING, and liver BIOPSY

21
Q

Explain Lab tests, Imaging, & Biopsy’s?

A

Lab tests used to 1) ASSESS liver FUNCTION and identify underlying 2) CAUSE of cirrhosis. The major lab findings in cirrhosis are:
● hypoalbuminemia
● ↑prothrombin time, ↑international normalized ratio (INR)
● thrombocytopenia
● ↑alkaline phosphatase (ALP)
● ↑aspartate transaminase (AST), ↑alanine transaminase (ALT), ↑g-glutamyl transpeptidase (GGT)
● Patients are also tested for viral hepatitis

Imaging
● Magnetic resonance elastography (MRE): a non-invasive advanced imaging to detect hardening/stiffening of liver
● Other imaging tests: MRI, CT, ultrasound

Biopsy (take out small piece of liver)
● It may be used to identify severity, extent, and cause of liver damage
- helps to assess severity of disease & how much liver damage

22
Q

What are the treatment strategies for cirrhosis?

A

● Cirrhosis is an irreversible disease and does not have any cure

● No specific treatment for cirrhosis is known

● Pharmacotherapies are used to treat:
- underlying causes to reduce liver damage - symptoms and complications of cirrhosis

● Avoiding ALCOHOL is recommended in all cases

● Treatment of hepatitis B and C with antiviral medication

● Liver transplantation: if cirrhosis leads to liver failure

23
Q

What are the treatment of ascites?

A

● Initial therapeutic paracentesis should be performed in
patients with tense ascites
● Sodium restriction (2,000 mg/day) and oral diuretics (spironolactone, furosemide)
● Diuretic-sensitive patients should be treated with sodium restriction and diuretics rather than serial paracentesis

24
Q

What are the refractory ascites treatment?

A

● SERIAL therapeutic paracenteses may be performed

● Post-paracenteses ALBUMIN infusion (8–10 g/L of fluid removed if >4–5 L are removed during paracenteses)

25
Q

What are the Prevention of variceal bleeding?

A

● Non-selective β-blockers: medium/large esophageal varices
● EBL (endoscopic band ligation): patients who have
contraindications or intolerance to nonselective β-blockers

26
Q

What is the Treatment of variceal bleeding?

A

● Antibiotic prophylaxis should be instituted on admission

● Vasoactive drugs prior to endoscopy, maintained for 2-5 days

● EBL is the recommended form of endoscopic therapy for acute esophageal variceal bleeding in conjunction with vasoactive drug therapy

27
Q

What is the Secondary prophylaxis of variceal bleeding?

A

● Nonselective β-blockers, EBL, or both should be used for prevention of recurrent variceal bleeding

28
Q

What is Treatment of portal hypertension?

A

● Lowering portal pressure with β-adrenergic blockers
● Severe cases: a small tube (trans-jugular intrahepatic
portosystemic shunt ) is placed in vein to reduce liver blood

29
Q

What is the Treatment of spontaneous bacterial peritonitis (SBP)?

A

● Ascitic fluid PMN>250 cells/mm3: empiric antibiotic therapy (eg cefotaxime)
● Ascitic fluid PMN<250 cells/mm3 & signs of infection: empiric antibiotic therapy while awaiting culture results

use broad spectrum - antibiotics don’t get to abd. quickly/well

30
Q

What is the Prophylaxis against SBP?

A

● Patients with gastrointestinal hemorrhage:
- norfloxacin or TMP/SMZ (trimethoprim- sulfamethoxazole); 7 days
- active bleeding: quinolone (IV)
– b/c bleeding is severe so must take IV not oral

● Patients who survive an episode of SBP should receive long-term prophylaxis with either daily norfloxacin or TMP/SMZ

(depends on patients situation)

broad spectrum

31
Q

What is the treatment of other infections?

A

● Antibiotics for treatment of infections
● Vaccination for hepatitis, influenza, pneumonia

32
Q

What is the treatment of Increased liver cancer risk?

A

● Periodic blood tests and ultrasound to monitor signs of liver cancer

33
Q

What is the treatment of hepatic encephalopathy?

A

● Medications and procedures to help reduce buildup of toxins in blood due to poor liver function

34
Q

What is Cirrhosis in pediatrics?

A

● *Cirrhosis is LESS common in children than adults

● Mechanism of developing cirrhosis and clinical
presentations are the SAME in children and adult
- signs/symptoms/complications would be the same as adults

● Causes of developing cirrhosis in kids are more related to GENETIC/INHERITED disease (eg alpha-1 antitrypsin, deficiency, biliary atresia)