Cirrhosis

Question 1

Common causes of cirrhosis

Answer 1

Hep B
Hep C
Alcohol
Hemochromatosis 
Wilson's disease
Non-alcoholic steatohepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Autoimmune hepatitis 
Alpha-1 antitrypsin deficiency 
Budd Chiari syndrome

Question 2

Examination findings of cirrhosis

Answer 2

Cachexia
Jaundice
Ascites
Spider angiomas
Dupuytren's contractures
Edema
Breast development 
Testicular atrophy 
Palmar erythema
Hair loss
Encephalopathy

Question 3

Lab findings in cirrhosis

Answer 3

Elevated bilirubin
Elevated transaminases
Elevated alk phos
Decreased albumin
Elevated PT/INR
Thrombocytopenia
Leukopenia
Renal insufficiency 
Hyponatremia

Question 4

What cell is responsible for cirrhosis?

Answer 4

Stellate cell!

Lays down collagen, obliterates Space of Disse, fenestrations go away, lose villi

Question 5

What criteria does the Child-Pugh Scoring Criteria look at?

Answer 5

Albumin
Bilirubin
INR
Ascites
Encephalopathy

Question 6

What are the 5 year survivals for class A, B and C Child-Pugh Scores?

Answer 6

A- 50-75% (liver transplant)
B- 40-45%
C- 10-15%

Question 7

What is the current method for identifying liver transplant needs?

Answer 7

Model for End-Stage Liver Disease (MELD)
Looks at INR
Bilirubin
Creatinine +/- dialysis
*At 15, the risk of transplant outweighs the mortality of liver disease

Question 8

What are some causes of portal hypertension?

Answer 8

Pre-hepatic: portal vein thrombosis

Intra-hepatic: cirrhosis

Post-hepatic: hepatic vein thrombosis (Budd-Chiari syndrome), Right heart failure, Valvular heart disease

Question 9

What are some complications of cirrhosis?

Answer 9

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

Question 10

What is used to prevent esophageal varicose?

Answer 10

Non-selective B-blockers (propranolol, nadolol)
-Decrease CO by blocking B-1 receptors
-Produce splanchnic vasoconstriction by B-2 blockade
Decreases risk of first bleed, rebelling and increases survival

Question 11

What is used to treat active esophageal bleeds?

Answer 11

Octreotide – decreases blood flow into portal vein
Somatostatin
Vasopressin
Terlipressin

Question 12

What is the pathophysiology of ascites?

Answer 12

Cirrhosis –> Increased resistance to portal flow –> portal hypertension –> Splanchnic arterial vasodilation –> Decreased effective circulating volume –> Activation of vasoconstrictor and antinatriuretic factors (RAAS) –> Na and H20 retention –> Plasma volume expansion –> Ascites

Question 13

What is the pathophysiology of hyponatremia in ascites?

Answer 13

Water retention is greater than sodium retention

Question 14

What is used to treat ascites?

Answer 14

2000 mg Na restricted diet

Diuretics: spironolactone (inhibits aldosterone), furosemide (lasix)

Question 15

What are some common signs and symptoms of someone with spontaneous bacterial peritonitis (SBP)??

Answer 15

Abdominal pain and fever

Also encephalopathy, hypoperistalsis, diarrhea, septic shock, GI bleed, vomit, asymptomatic

Question 16

What pathogens are responsible for SBP?

Answer 16

E. coli 
Streptococci 
Klebsiella
Other gram negatives
Anaerobes

Question 17

What is hepatorenal syndrome?

Answer 17

Complication of ascites

Progressive renal failure associated with advanced cirrhosis and ascites

Question 18

What are some differentials of renal failure in cirrhosis?

Answer 18

Acute tubular necrosis
Pre-renal
Hepatorenal syndrome

Question 19

What is hepatopulmonary syndrome?

Answer 19

Complication of ascites

Vasodilation syndrome in the lungs – no treatment besides liver transplant

Question 20

What is the pathophysiology of hepatic encephalopathy?

Answer 20

Gut derived neurotoxins –> hepatic insufficiency and hepatic bypass –> cross BBB –> CNS changes

Question 21

What is the treatment for hepatic encephalopathy?

Answer 21

Lactulose –> lactic acid and decreases pH and allows NH4+ to be protonated and excreted

If lactulose doesn’t work Rifaximin

Question 22

What is the most common cause of acute liver failure in the USA?

Answer 22

Acetominophen

Question 23

What is fulminant liver failure?

Answer 23

Acute liver failure – hepatocyte necrosis –> coagulopathy, encephalopathy

Cerebral edema: inability of liver to metabolize ammonia, ammonia and glutamate are converted by action of glutamine synthetase into glutamine by brain astrocytes –> astrocyte swelling leads to cerebral edema, cerebral herniation is leading cause of death