Cirrhosis

Question 1

Which types of hepatitis can cause acute liver failure but not cirrhosis?

Answer 1

Hepatitis A and Hepatitis E

Question 2

What are some exam findings associated with Cirrhosis?

Answer 2

• Cachexia (muscle wasting)
• Jaundice
• Ascites
• Spider Angioma
• Duputyren’s contractures
• Edema
• Breast development
• Palmar erythema

Question 3

Where are spider angiomas found and how do they appear?

Answer 3

Often present above level of the belly button - small arterial/venous dilations on the skin

Question 4

What hormone leads to palmar erythema? How is this associated with liver disease?

Answer 4

Estrogen

The liver decreases estrogen levels so its dysfunction leads to increased estrogen

Question 5

What is a consequence of the narrowing of tendons in cirrhosis?

Answer 5

Duputren’s contractures

Question 6

How does cirrhosis lead to caput medussa?

Answer 6

Varicose veins dilate on the abdominal wall due the need for blood to bypass the liver

Question 7

How does cirrhosis lead to edema?

Answer 7

The liver cannot produce as much protein and this decreases the oncotic pressure intravascularly which leads to edema

Question 8

What makes up the dark rim around the liver in this image?

Answer 8

Fluid - leading to ascites

Question 9

How does hepatic fibrosis involve stellate cells?

Answer 9

Stellate cells are overactivated and lay down collagen in the space of disse

Question 10

What abnormalities add 1 point to the Child Pugh scoring criteria?

Albumin:

Bilirubin:

INR:

Ascites:

Encephalopathy:

Answer 10

Albumin: >3.5 g/dL

Bilirubin: <2 mg/dL

INR: <1.70 seconds

Ascites: None

Encephalopathy None

Question 11

What abnormalities add 2 points to the Child Pugh scoring criteria?

Albumin:

Bilirubin:

INR:

Ascites:

Encephalopathy:

Answer 11

Albumin: 2.8-3.5 g/dL

Bilirubin: 2-3 mg/dL

INR: 1.71-2.20 seconds

Ascites: Easily controlled with diuretics

Encephalopathy: Easily controlled with lactulose

Question 12

What abnormalities add 3 points to the Child Pugh scoring criteria?

Albumin:

Bilirubin:

INR:

Ascites:

Encephalopathy:

Answer 12

Albumin: <2.8 g/dL

Bilirubin: >3 mg/dL

INR: >2.20 seconds

Ascites: Poorly controlled with diuretics

Encephalopathy: Poorly controlled with lactulose

Question 13

Child Pugh class

• A score of 5-6 is considered ______
• A score of 7-9 is considered ______
• A score of >9 is considered ______

Answer 13

A score of 5-6 is considered compensated
A score of 7-9 is considered decompensated
A score of >9 is considered decompensated

Question 14

What 4 factors make up the MELD score (model for end-stage liver disease)?

Answer 14

• INR
• Bilirubin
• Creatanine
• Dialysis at least twice in the past week

Question 15

What are the three types of portal hypertension?

Which type is associated with cirrhosis?

Answer 15

1. Pre-hepatic (Portal vein thrombosis)
2. Intra-hepatic (associated with cirrhosis)
3. Post-hepatic (enlargement of sinusoids)

Question 16

How does the hepatic artery attempt to compensate for an increase in portal vein pressure?

Answer 16

The hepatic artery dilates (to compensate for decreased blood flow to the liver)

Question 17

What are some complications of Cirrhosis?

Answer 17

• Variceal bleeding
• Ascites
• Spontaneous bacterial peritonitis (SBP)
• Hepatorenal Syndrome
• Hepatopulmonary Syndrome
• Hepatic encephalopathy

Question 18

How does cirrhosis lead to leukopenia and thrombocytopenia?

Answer 18

• Blood is shunted into the spleen with increased pressure in the liver
• Increaed blood flow to spleen causes splenomegaly
• Splenomegaly causes the spleen to sequester platelets and WBCs leading to leukopenia and thrombocytopenia

Question 19

What medications are used to reduce risk of rupture and bleeding in esophageal varices? (not for actively bleeding patients)

Answer 19

• Non-selective B-blockers (propanalol and nadolol)
  
  • Decrease cardiac output by blocking B-1 receptors
  • Produce splanchnic vasoconstriction by B2 blockade

Question 20

How are active variceal hemorrhages treated?

What other treatment can prevent futue bleeding episodes?

Answer 20

Octreotide (Somatostatin analog) - decreases amount of blood flow through portal vein

Varceal Band Ligation - For patients who cannot tolerate beta blockers

Question 21

Describe the pathophysiology of ascites from cirrhosis (10 steps)

Answer 21

Cirrhosis → Increased resistance to portal flow → Portal hypertension → Splanchnic arterial vasodilation → Decreased effective circulating volume → Activation of vasoconstrictor and antinatriuretic factors → Sodium and water retention → Plasma volume expansion → ascites

Question 22

How does cirrhosis lead to hyponatremia?

Answer 22

• Decreased effective circulating volume leads to increased vasopressin and renin-angiotensin/aldosterone
• This leads to increased water and sodium retention
• Eventually water retention is greater than sodium retention leading to hyponatremia

Question 23

How is ascites managed?

Answer 23

• 2000mg sodium restricted diet
• Diuretics
  
  • Spironolactone - inhibits aldosterone (thiazide diuretic)
  • Furosemide - lowers potassium (loop diuretic)

Question 24

What are the top two symptoms in patients with SBP (spontaneous bacterial peritonitis)?

Answer 24

Abdominal pain (80%) and fever (70%)

Question 25

What are the top two bacterial pathogens in SBP?

Answer 25

Mostly gram negatives

• E. Coli
• Streptococci

Question 26

Describe hepatorenal syndrome

Answer 26

Progressive renal failure associated with advanced cirrhosis and ascites

Question 27

What are three differential diagnoses of renal failure in cirrhosis? What urine sodium level is associated with each?

Answer 27

• Acute tubular necrosis (>20 mEq/L sodium)
• Pre-Renal (<10)
• Hepatorenal syndrome (<10)

Question 28

Hepatopulmonary syndrome causes _____ of vasculature

Answer 28

dilation (due to backup)

Question 29

How can the decrease in blood flow to the lungs be improved in hepatopulmonary syndrome?

Answer 29

Increase oxygen intake

Question 30

How does cirrhosis lead to mental status changes (Hepatic Encephalopathy)?

Answer 30

Gut-derived neurotoxins → Hepatic Insufficiency/Hepatic Bypass → Crossing of BBB → CNS changes

Question 31

What neuromuscular disorder is also associated with Hepatitc encephalopathy?

Answer 31

Asterixis - impaired communication with brain stem leads to involuntary wrist movement

Question 32

What metnal status changes are associated with the different levels of hepatic encephalopathy?

• Grade 0:
• Grade 1:
• Grade 2:
• Grade 3:
• Grade 4:

Answer 32

• Grade 0: no alteration in consciousness, intellectual function, or behavior
• Grade 1: Trivial lack of awareness, euphoria or anxiety, short attention span
• Grade 2: Lethargy, disorientation, personality change, inapproptiate behavior
• Grade 3: Somnolence to semistupor, confusion, response to noxious stimuli
• Grade 4: Coma, no response to noxious stimuli

Question 33

What are three mechanisms in hepatic encephalopathy treatment with lactulose?

Answer 33

• Lactulose is cathartic - keeps colon clean
• Lactulose lowers pH (increases lactic acid)
• Lactulose causes protonation of NH₃ → NH₄⁺

Question 34

How does Lactulose compare with Rifaximin in HE treatment?

Answer 34

Lactulose is less effective at decreasing asterixis but is also less expensive compared to Rifaximin

Question 35

What is the most common origin of acute liver failure in the the USA

Answer 35

Acetaminophin

Question 36

What are the components of fulminant liver failure?

Answer 36

• Acute liver failure
  
  • hepatocyte necrosis
• Cerebral edema (most likely cause of death)
  
  • Inability of liver to metabolize ammonia
  • Astrocyte swelling and cerebral herniation