Cirrhosis Flashcards
Which types of hepatitis can cause acute liver failure but not cirrhosis?
Hepatitis A and Hepatitis E
What are some exam findings associated with Cirrhosis?
- Cachexia (muscle wasting)
- Jaundice
- Ascites
- Spider Angioma
- Duputyren’s contractures
- Edema
- Breast development
- Palmar erythema
Where are spider angiomas found and how do they appear?
Often present above level of the belly button - small arterial/venous dilations on the skin
What hormone leads to palmar erythema? How is this associated with liver disease?
Estrogen
The liver decreases estrogen levels so its dysfunction leads to increased estrogen
What is a consequence of the narrowing of tendons in cirrhosis?
Duputren’s contractures
How does cirrhosis lead to caput medussa?
Varicose veins dilate on the abdominal wall due the need for blood to bypass the liver
How does cirrhosis lead to edema?
The liver cannot produce as much protein and this decreases the oncotic pressure intravascularly which leads to edema
What makes up the dark rim around the liver in this image?
Fluid - leading to ascites
How does hepatic fibrosis involve stellate cells?
Stellate cells are overactivated and lay down collagen in the space of disse
What abnormalities add 1 point to the Child Pugh scoring criteria?
Albumin:
Bilirubin:
INR:
Ascites:
Encephalopathy:
Albumin: >3.5 g/dL
Bilirubin: <2 mg/dL
INR: <1.70 seconds
Ascites: None
Encephalopathy None
What abnormalities add 2 points to the Child Pugh scoring criteria?
Albumin:
Bilirubin:
INR:
Ascites:
Encephalopathy:
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
What abnormalities add 3 points to the Child Pugh scoring criteria?
Albumin:
Bilirubin:
INR:
Ascites:
Encephalopathy:
Albumin: <2.8 g/dL
Bilirubin: >3 mg/dL
INR: >2.20 seconds
Ascites: Poorly controlled with diuretics
Encephalopathy: Poorly controlled with lactulose
Child Pugh class
- A score of 5-6 is considered ______
- A score of 7-9 is considered ______
- A score of >9 is considered ______
A score of 5-6 is considered compensated
A score of 7-9 is considered decompensated
A score of >9 is considered decompensated
What 4 factors make up the MELD score (model for end-stage liver disease)?
- INR
- Bilirubin
- Creatanine
- Dialysis at least twice in the past week
What are the three types of portal hypertension?
Which type is associated with cirrhosis?
- Pre-hepatic (Portal vein thrombosis)
- Intra-hepatic (associated with cirrhosis)
- Post-hepatic (enlargement of sinusoids)
How does the hepatic artery attempt to compensate for an increase in portal vein pressure?
The hepatic artery dilates (to compensate for decreased blood flow to the liver)
What are some complications of Cirrhosis?
- Variceal bleeding
- Ascites
- Spontaneous bacterial peritonitis (SBP)
- Hepatorenal Syndrome
- Hepatopulmonary Syndrome
- Hepatic encephalopathy
How does cirrhosis lead to leukopenia and thrombocytopenia?
- 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
What medications are used to reduce risk of rupture and bleeding in esophageal varices? (not for actively bleeding patients)
- Non-selective B-blockers (propanalol and nadolol)
- Decrease cardiac output by blocking B-1 receptors
- Produce splanchnic vasoconstriction by B2 blockade
How are active variceal hemorrhages treated?
What other treatment can prevent futue bleeding episodes?
Octreotide (Somatostatin analog) - decreases amount of blood flow through portal vein
Varceal Band Ligation - For patients who cannot tolerate beta blockers
Describe the pathophysiology of ascites from cirrhosis (10 steps)
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
How does cirrhosis lead to hyponatremia?
- 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
How is ascites managed?
- 2000mg sodium restricted diet
- Diuretics
- Spironolactone - inhibits aldosterone (thiazide diuretic)
- Furosemide - lowers potassium (loop diuretic)
What are the top two symptoms in patients with SBP (spontaneous bacterial peritonitis)?
Abdominal pain (80%) and fever (70%)
What are the top two bacterial pathogens in SBP?
Mostly gram negatives
- E. Coli
- Streptococci
Describe hepatorenal syndrome
Progressive renal failure associated with advanced cirrhosis and ascites
What are three differential diagnoses of renal failure in cirrhosis? What urine sodium level is associated with each?
- Acute tubular necrosis (>20 mEq/L sodium)
- Pre-Renal (<10)
- Hepatorenal syndrome (<10)
Hepatopulmonary syndrome causes _____ of vasculature
dilation (due to backup)
How can the decrease in blood flow to the lungs be improved in hepatopulmonary syndrome?
Increase oxygen intake
How does cirrhosis lead to mental status changes (Hepatic Encephalopathy)?
Gut-derived neurotoxins → Hepatic Insufficiency/Hepatic Bypass → Crossing of BBB → CNS changes
What neuromuscular disorder is also associated with Hepatitc encephalopathy?
Asterixis - impaired communication with brain stem leads to involuntary wrist movement
What metnal status changes are associated with the different levels of hepatic encephalopathy?
- Grade 0:
- Grade 1:
- Grade 2:
- Grade 3:
- Grade 4:
- 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
What are three mechanisms in hepatic encephalopathy treatment with lactulose?
- Lactulose is cathartic - keeps colon clean
- Lactulose lowers pH (increases lactic acid)
- Lactulose causes protonation of NH3 → NH4+
How does Lactulose compare with Rifaximin in HE treatment?
Lactulose is less effective at decreasing asterixis but is also less expensive compared to Rifaximin
What is the most common origin of acute liver failure in the the USA
Acetaminophin
What are the components of fulminant liver failure?
- Acute liver failure
- hepatocyte necrosis
- Cerebral edema (most likely cause of death)
- Inability of liver to metabolize ammonia
- Astrocyte swelling and cerebral herniation
