Cirrhosis Flashcards
etiologies of portal hypertension
- prehepatic:
-portal vein thrombosis - intrahepatic:
-presinusoidal: schistosomiasis
-sinusoidal: CIRRHOSIS, infiltrative disorders
-postsinusoidal: sinusoidal obstructive syndrome - posthepatic:
-Budd Chiari syndrome, R heart failure, constrictive pericarditis
pathogenesis of portal hypertension
*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
clinical clues to the presence of cirrhosis
*PE: SPLENOMEGALY, ASCITES, spider angiomata, edema
*lab tests: THROMBOCYTOPENIA, hypoalbuminemia, prolonged PT
*imaging: nodular liver, splenomegaly, ascites, large collaterals
stages of cirrhosis
- compensated cirrhosis - mild portal hypertension but mostly asymptomatic; good median survival rates
- 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
complications of cirrhosis
- GI bleeding
- ascites
- hepatic encephalopathy
- hepatocellular carcinoma (HCC)
GI bleeding - complication of cirrhosis & portal hypertension
*esophageal varices
*gastric varices
*portal hypertensive gastropathy
portal vein pressure necessary for variceal hemorrhage
> or equal to 12 mmHg
treatment of esophageal variceal hemorrhage
*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
ascites - complication of cirrhosis & portal hypertension
*accumulation of fluid in the peritoneal space
*500 cc before clinically evident
*ddx: portal HTN, malignant ascites, nephrotic syndrome, TB
serum-ascites albumin gradient (SAAG)
SAAG = serum albumin - ascites albumin
*greater than or equal to 1.1 in ascites caused by portal hypertension/cirrhosis
portal vein pressure necessary for ascites
> or equal to 10 mmHg
ascites - physical diagnosis
*flank dullness
*shifting dullness
*lower extremity edema!!
*check neck veins (if distended, probably cardiac cause)
GOLD STANDARD = ULTRASOUND
treatment of ascites
*sodium restriction + diuretic therapy (spironolactone and furosemide)
refractory ascites and treatment
refractory ascites is ascites that cannot be mobilized by sodium restriction & diuretic therapy
tx:
*large volume paracentesis
*TIPS procedure
spontaneous bacterial peritonitis (SBP)
*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
treatment of spontaneous bacterial peritonitis (SBP)
*IV antibiotics (cephalosporin) and IV albumin
prophylaxis: daily norfloxacin or ciprofloxacin
hepatorenal syndrome (HRS)
*complication of ascites
*related to vasoconstriction of kidneys & renal hypoperfusion
hepatorenal syndrome - treatment
*vasoconstrictor drug (terlipressin, NE, or midodrine and octreotide) + albumin
pulmonary complications of portal hypertension
*hepatopulmonary syndrome (increased A-a gradient, liver disease, evidence of IPVDs)
*portopulmonary syndrome
*hepatic hydrothorax!
hepatic hydrothorax
*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
hepatic encephalopathy
*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
hepatic encephalopathy - diagnosis
*hx: sleep disturbances (insomnia/hypersomnia), lethargy, somnolence, confusion
*exam: asterixis, hyperreflexia, fetor hepaticus
*labs: BMP, drug screen, AMMONIA level
*CT head
hepatic encephalopathy - treatment
*correct precipitating factors
*LACTULOSE, dosed to achieve 2-3 soft bowel movements daily
*antibiotics (RIFAXIMIN)
*consider safety issues (driving)
MELD score - use & contributing factors
*used to determine who should get a liver transplant soonest; correlates well with survival
*3 factors contribute:
-bilirubin
-INR
-creatinine
