Cirrhosis

Question 1

etiologies of portal hypertension

Answer 1

1. prehepatic:
   -portal vein thrombosis
2. intrahepatic:
   -presinusoidal: schistosomiasis
   -sinusoidal: CIRRHOSIS, infiltrative disorders
   -postsinusoidal: sinusoidal obstructive syndrome
3. posthepatic:
   -Budd Chiari syndrome, R heart failure, constrictive pericarditis

Question 2

pathogenesis of portal hypertension

Answer 2

*increased intrahepatic resistance leads to increased portal pressure
*increased splanchnic blood flow causes increased portal venous blood
*development of varices, which can rupture and bleed

Question 3

clinical clues to the presence of cirrhosis

Answer 3

*PE: SPLENOMEGALY, ASCITES, spider angiomata, edema
*lab tests: THROMBOCYTOPENIA, hypoalbuminemia, prolonged PT
*imaging: nodular liver, splenomegaly, ascites, large collaterals

Question 4

stages of cirrhosis

Answer 4

1. compensated cirrhosis - mild portal hypertension but mostly asymptomatic; good median survival rates
2. decompensated cirrhosis - characterized by the presence of ASCITES, VARICEAL HEMORRHAGE, or HEPATIC ENCEPHALOPATHY; time to be referred for a transplant if you are a candidate

Question 5

complications of cirrhosis

Answer 5

1. GI bleeding
2. ascites
3. hepatic encephalopathy
4. hepatocellular carcinoma (HCC)

Question 6

GI bleeding - complication of cirrhosis & portal hypertension

Answer 6

*esophageal varices
*gastric varices
*portal hypertensive gastropathy

Question 7

portal vein pressure necessary for variceal hemorrhage

Answer 7

> or equal to 12 mmHg

Question 8

treatment of esophageal variceal hemorrhage

Answer 8

*acute therapy: goal = reduce splanchnic blood flow (OCTREOTIDE + antibiotics, endoscopic variceal ligation, minnesota tube, TIPS)

*prevention: beta-blocker (decreased cardiac output), endoscopic variceal ligation, TIPS

Question 9

ascites - complication of cirrhosis & portal hypertension

Answer 9

*accumulation of fluid in the peritoneal space
*500 cc before clinically evident
*ddx: portal HTN, malignant ascites, nephrotic syndrome, TB

Question 10

serum-ascites albumin gradient (SAAG)

Answer 10

SAAG = serum albumin - ascites albumin

*greater than or equal to 1.1 in ascites caused by portal hypertension/cirrhosis

Question 11

portal vein pressure necessary for ascites

Answer 11

> or equal to 10 mmHg

Question 12

ascites - physical diagnosis

Answer 12

*flank dullness
*shifting dullness
*lower extremity edema!!
*check neck veins (if distended, probably cardiac cause)

GOLD STANDARD = ULTRASOUND

Question 13

treatment of ascites

Answer 13

*sodium restriction + diuretic therapy (spironolactone and furosemide)

Question 14

refractory ascites and treatment

Answer 14

refractory ascites is ascites that cannot be mobilized by sodium restriction & diuretic therapy

tx:
*large volume paracentesis
*TIPS procedure

Question 15

spontaneous bacterial peritonitis (SBP)

Answer 15

*ascitic fluid infection that occurs in the absence of an obvious source of infection
*unique complication of cirrhotic ascites
*organisms: E. coli most common; Klebsiella pneumoniae; Strep pneumo

*dx is established w/ an ascites fluid PMN > 250 cells/mm3

Question 16

treatment of spontaneous bacterial peritonitis (SBP)

Answer 16

*IV antibiotics (cephalosporin) and IV albumin

prophylaxis: daily norfloxacin or ciprofloxacin

Question 17

hepatorenal syndrome (HRS)

Answer 17

*complication of ascites
*related to vasoconstriction of kidneys & renal hypoperfusion

Question 18

hepatorenal syndrome - treatment

Answer 18

*vasoconstrictor drug (terlipressin, NE, or midodrine and octreotide) + albumin

Question 19

pulmonary complications of portal hypertension

Answer 19

*hepatopulmonary syndrome (increased A-a gradient, liver disease, evidence of IPVDs)
*portopulmonary syndrome
*hepatic hydrothorax!

Question 20

hepatic hydrothorax

Answer 20

*pleural effusions of > 500 cc in patients with cirrhosis and no underlying cardiac or pulmonary disease
*likely cause is passage of ascites fluid through small defects in the diaphragm
*because of negative intrathoracic pressure, most patients only have mild ascites
*usually unilateral right-sided effusion
*typical sx: dyspnea, cough

Question 21

hepatic encephalopathy

Answer 21

*a complication of portal hypertension/cirrhosis
*a syndrome of reversible brain dysfunction in the setting of significant liver disease
*pathogenesis likely multifactorial (ammonia, GABA, etc)
*decreased hepatic clearance of AMMONIA due to liver dysfunction, portosystemic shunts

Question 22

hepatic encephalopathy - diagnosis

Answer 22

*hx: sleep disturbances (insomnia/hypersomnia), lethargy, somnolence, confusion
*exam: asterixis, hyperreflexia, fetor hepaticus
*labs: BMP, drug screen, AMMONIA level
*CT head

Question 23

hepatic encephalopathy - treatment

Answer 23

*correct precipitating factors
*LACTULOSE, dosed to achieve 2-3 soft bowel movements daily
*antibiotics (RIFAXIMIN)
*consider safety issues (driving)

Question 24

MELD score - use & contributing factors

Answer 24

*used to determine who should get a liver transplant soonest; correlates well with survival

*3 factors contribute:
-bilirubin
-INR
-creatinine