Cirrhosis

Question 1

The histologic characterization of cirrhosis is ___________.

Answer 1

fibrosis with regenerative nodules

Question 2

There are two kinds of cirrhosis: ________________.

Answer 2

• compensated: no complications
• uncompensated: complications (portal hypertension – leading to varices and ascites – and liver insufficiency –leading to encephalopathy and jaundice)

Question 3

Hypertrophy of which liver lobe is indicative of cirrhosis?

Answer 3

The caudate

Question 4

True or false: biopsy is needed for definitive diagnosis of cirrhosis.

Answer 4

False. Cirrhosis can be diagnosed on CT or by clinical features –even to the point of transplant list! Only do a biopsy if someone has chronic liver disease and no other manifestations of cirrhosis.

Question 5

What five criteria are in the Child-Turcotte-Pugh scale?

Answer 5

• ascites
• encephalopathy
• bilirubin
• albumin
• PT/INR

Question 6

The MELD scale includes which three serum values?

Answer 6

• creatinine
• bilirubin
• PT/INR

Question 7

The most common cause of portal hypertension is ___________.

Answer 7

cirrhosis

Question 8

Post-sinusoidal occlusion often results from what kind of medical intervention?

Answer 8

Myeloablative therapy (for cancer)

Question 9

What two things happen in cirrhosis that leads to portal hypertension?

Answer 9

(1) Fibrosis leads to structural interference
(2) Destruction of endothelial cells leads to decreased NO release and subsequent increase in vasoconstriction (whereas in healthy tissue, increased flow would lead to increased NO release and subsequent vasodilation)

Question 10

The definitive diagnostic test for cirrhosis is _____________.

Answer 10

hepatic venous pressure gradient (HVPG)

Question 11

HVPG is normal in ____________ portal hypertension, while it will be elevated in ____________________ portal hypertension.

Answer 11

pre-hepatic, pre-sinusoidal, and post-hepatic; sinusoidal and post-sinusoidal

Question 12

______________ esophageal varices are more likely to rupture.

Answer 12

Large (which increase the wall tension)

Question 13

Esophageal varices can be treated with ____________.

Answer 13

endoscopic band ligation

Question 14

There is a surgical treatment for cirrhosis that is analogous to drilling a hole through the liver. What is it?

Answer 14

Transjugular intrahepatic portosystemic shunt –connecting the hepatic portal vein to the hepatic vein.

Question 15

What is the use of octreotide? (This is going to be on the exam!) “Give octreotide before calling the GI fellow.”

Answer 15

It causes vasoconstriction in the splanchnic vasculature. This causes constriction of the stomach/esophageal veins, leading to temporary inhibition of bleeding.

Question 16

The most common cause ascites is ___________.

Answer 16

cirrhosis (80%)

Question 17

One of the things that induces sodium retention is _____________.

Answer 17

over dilation of the splanchnic vasculature (from portal hypertension)

Question 18

After paracentesis, what calculation can be done to help diagnose ascites?

Answer 18

(serum albumin) –(ascites albumin)

If this is greater than 1.1, this is cirrhotic ascites. (This also correlates well with HVPG.)

Question 19

______________ often presents earlier than hypoalbuminemia or prolonged INR in those with cirrhosis.

Answer 19

Thrombocytopenia (because of hypersplenism)

Question 20

The CTP scale goes from 5 to 15. You need a score of at least _______ to be put on the transplant list.

Answer 20

7

Question 21

MELD stands for ________________.

Answer 21

Model for End-stage Liver Disease

Question 22

In cirrhosis, the site of increased resistance is ______________.

Answer 22

sinusoidal

Question 23

List the sites which can cause portal hypertension and the most common cause of each.

Answer 23

• pre-hepatic: portal vein thrombosis
• pre-sinusoidal: Schistosomiasis
• sinusoidal: cirrhosis
• post-sinusoidal: veno-occlusive disease
• post-hepatic: Budd-Chiari or CHF

Question 24

Normal HVPG is ________.

Answer 24

3 to 6 mmHg

Question 25

In addition to inhibiting the release of gastrin and histamine, octreotide also ______________.

Answer 25

causes vasoconstriction

Question 26

Up to half of the cases of SBP may be _______________.

Answer 26

asymptomatic

Question 27

A SAAG greater than 1.1 indicates ___________, while a SAAG less than 1.1 indicates _____________.

Answer 27

that the ascites is due to portal hypertension; that the ascites is peritoneal in origin

Question 28

The best initial treatment for ascites is _____________.

Answer 28

diuretics and salt-restriction diets, which counteract the body’s pathologic retention of water and sodium in ascites

Question 29

What does giving albumin to someone with ascites do?

Answer 29

It promotes plasma-volume expansion, which increases effective arterial volume.

Question 30

What are the two types of hepatorenal syndrome?

Answer 30

1: rapidly progressive (doubling of creatinine in a two-week period); two-week mortality
2: slowly progressive; associated with refractory ascites; six-month mortality

Question 31

Large-volume paracentesis can cause ___________.

Answer 31

hepatorenal syndrome

Question 32

Liver transplantation can cure HRS if done within ____________.

Answer 32

4-6 weeks of onset

Question 33

True or false: SBP can be caused by an intestinal abscess.

Answer 33

False. By definition, SBP does not have an identifiable cause and thus results only from gut leakage.

Question 34

The diagnosis of SBP relies on _______________.

Answer 34

PMN count greater than 250 per mL

Question 35

___________ has a high rate of recurrence.

Answer 35

SBP

Question 36

True or false: ammonia levels help diagnose hepatic encephalopathy.

Answer 36

False. Ammonia levels are notoriously unreliable in hepatic encephalopathy.

Question 37

Those with _____________ have first priority for liver transplant. After that, those with the highest _______ score do.

Answer 37

fulminant liver failure; MELD

Question 38

In Colorado, you need a MELD score above ______ to receive a liver transplant.

Answer 38

30

Question 39

_____________ is the most sensitive test for ascites.

Answer 39

Ultrasound

Question 40

Cardiac ascites and cirrhotic ascites both have elevated SAAG. How can you test ascitic fluid to distinguish the two?

Answer 40

Cardiac ascites has more protein

Question 41

What two criteria are absolutely needed for diagnosis of hepatorenal syndrome?

Answer 41

Ascites and hyponatremia