Cirrhosis Flashcards
Which AI hep is more severe
Type 2
Stages of cirrhosis
Stage 1
Stage 2 - varices, no ascites
Decompesnation event (HVPG >12mmHg)
Stage 3 - bleeding
Stage 4 - first non bleeding decompensation - ascites, HE, jaundice
Stgae 5 - second decompensation
How does portal HPTN occur
→ Liver failure +splanchic vasodilation → increased portal blood inflow - increased portal pressure → varices → bleeding
Cirrhosis effects on systemic circulation
- Vasodilation
- Hypotension
- Increased plasma volume
- Increased cardiac index
→ hypovolaemia→ RAAS + Na retention → ascites
What are signs of decompensation in cirrhosis
Jaundice
Increasing ascites
Hepatic encephalopathy
Renal impariment/hypovolaemia
Signs of spesis
What can precipitate a decompensation in liver disease
GI bleeding
Infection/sepsis
Alcohol Drugs - opiates, NSAIDs
HCC
Portal vein thrombosis
Dehydration
Contipation - encephalopathy
How analyse asciic fluid and when done
Paracentesisi
New ascites, cirrhotic patient with ascites in hospital
What is SAAG
Albumin in serum:ascites
What does a SAAG >11 suggest
ascites due to portal HPTN
Causes of ascites SAAG >11
Portal HPTN
Cardiac failure
Portal vein thrombosis
Hypothyroidism
Causes of ascites where SAAG <11
Pertionneal carcinomastosis
Peritonneal TB
Panceratitis
Bowel perforation
Nephrotic syndrome
What get in SBP
Fever, abdo pain, renal impairment or asymptomatic
What find in ascitic tap in SBP
Polymorphonucear cells >250m3
Neutrophils 0.25x109
Treatment SBP
Anitbiotics - test for sensitivities - co-amoxilav or ciprofloxacin
Ascites management
Na restrict, diuretics #
TIPS
Large volume paracentesis
Liver transplant
Criteria for diagnosis of hepatorenal syndrome exclusion
Cirrhosis, ALF
Criteria for fialing kidneys urine output/creatinine >50%
No full or partial response after 2 days diuretic withdrawal + volume expansion with albumin
Absence of shock
No current or recent nephrotoxic drugs
Absence of parenchymal disease - proteinuria, haematuria, urinary biomarkers
FeNa <0.2% (renal vasoconstriction)
Kidney crtieria for hepatorenal syndrome - class 1
Absolute increase in sCR >0.3 mg/dL in 48 hrs
Urinary output <0.5ml/kg BW >6 hrs
% increase in sCR >50% using last available value of outpatient sCr within 3 months
Resus for a variceal bleed
Intubation consider
High flow O2
IV access
Blood transfusion
Antibiotics
Terlipressin/somatostatin
If fail -> balloon
tamponade
If unstable immediate gastroccopy
After resus management of variceal bleed
Gastroscopy within 24 hours - separate oesophageal vs gastric origin
Oesophageal variceal bleed management
Band ligation
Success -> sedonary prophylaxis after 5 days
Secondary prophylaxis varcies oesophageal
VBL + non selective beta blcker
Who do a TIPS within 72 hrs of bleed in (after haemostasois)
Childs pugh B + active bleed
Childs pugh C + ,14 - 1b, grade B
Gastric variceals treatment
Cryanoacrylate injection or trombin
Consider SBB
TIPS if large or multiple barices
First line for rebleed varices
Salvage TIPS
Balloon tamponae until can do a TIPS
Alternative to TIPS
Balloon occulded retrograde transvenus obliteration or surgical shunt
How monitor if no varices on endoscopy
Re endosocpe in 2-3 years
What do if Grade I varices on endoscopy
Re-endsocope in 1 year