Cirrhosis

Question 1

Cirrhosis general info

Answer 1

• Suspect in anyone with increased ALT/AST, chronic liver disease
• Assessing mortality
  • Child-­Turcotte-­Pugh (CTP) Score: rated (1-­‐ 3) on encephalopathy, ascites, bilirubin, albumin, PT/INR
  –> score of 7 for transplant
  • Model for End-­Stage Liver
  Disease (MELD): estimates risk of 3 month mortality using lab values of bilirubin, creatinine and INR –> used for transplant

Question 2

Cirrhosis presentation

Answer 2

Can be incidental finding or because have symptoms of failure (jaundice, spider angioma, caput medusae, ascites, gynecomastia, splenomegaly)

Question 3

Cirrhosis Labs/diagnostics

Answer 3

• Low albumin
• Prolonged PT (INR>1.3)
• High bilirubin
• Low platelet count
• Imaging (nodular liver, caudate hypertrophy, ascites, splenomeg, venous
  collaterals, hepatocellular carcinoma)
• Biopsy is NOT necessary todiagnosis (and
  NOT needed for transplant)
• Fibrous septation incorporating portal tracts and central veins

Question 4

Portal hypertension info

Answer 4

• From increased flow, increased resistance
  or both
• Increased resistance from increased fibrosis AND decreased NO (=vasoconstriction) IN THE LIVER
• Increased flow from increased shear stress and increased NO (vasodilation=inc. flow) OUTSIDE OF LIVER

Question 5

Portal hypertension causes

Answer 5

• Pre-­hep: portal or splenic vein thrombosis
• Pre-­sinusoidal: Schistosomiasis
• Sinusoidal: cirrhosis (most common)
• Post-­sinusoidal: veno-­‐occlusive disease
• Post-­hepatic: Budd-­‐Chiari syndrome (hepatic vein thrombosis); CHF

Question 6

Portal hypertension presentation

Answer 6

 Varices
 Ascites
 Progression to hepatorenal syndrome

Question 7

Portal hypertension labs / diagnostic

Answer 7

Measurement of hepatic venous pressure gradient (HVPG)
- HVPG = WHVP - ­FHVP
*WHVP: Wedged HVP
* FHVP: Free HVP (systemic VP)
*

Question 8

Portal hypertension treatment

Answer 8

• Vasoconstrictors (octreotide!!!) to decrease portal flow –> use first in emergent cirrhotic patient
• Vasodilators to increase intrahepatic resistance
• Transjugular Intrahepatic Portosystemic Shunt (TIPS) –> connect branch of hepatic vein with portal vein (complications=liver failure and encephalopathy)

Question 9

Varices info

Answer 9

• Factors assoc with variceal growth: Child Score B/C cirrhosis, EtOH etiology, red wale marks on endoscopy
• Can lead to variceal hemorrhage (biggest predictor is size)

Question 10

Varices presentation and labs / diagnostics

Answer 10

Tortuous, bulging vein –> especially in esophagus, rectum. endoscopy