Cirrhosis

Question 1

What happens to the blood supply of the liver when it is cirrhotic?

Answer 1

blockage of the blood flow causing abnormal signalling

Question 2

What are the normal hepatic and portal vein and hepatic artery pressures?

Answer 2

Hepatic vein pressure = 4 mmHg

Portal vein pressure = 7 mmHg

Hepatic artery pressure = 100 mmHg

Question 3

During portal hypertension, what may happen to portocaval astamoses?

Answer 3

become engorged, dilated, or varicosed and subsequently rupture

Question 4

What defines portal hypertension?

Answer 4

Portal vein - Hepatic vein pressure gradient greater than 5 mm Hg

Question 5

What does portal hypertension result from?

Answer 5

Increased resistance to portal flow (R)

Increased portal venous inflow (Q)

Question 6

What are the two classes of portal hypertension causes?

Answer 6

Prehepatic – blockage of the portal vein before the liver; due to portal vein thrombosis or occlusion secondary to congenital portal venous abnormalities

Intrahepatic - due distortion of the liver architecture, either
presinusoidal (e.g. schistosomiasis, or Non-cirrhotic Portal Hypertension)
postsinusoidal (e.g. cirrhosis); causes include: cirrhosis, alcoholic hepatitis, congenital hepatic fibrosis

Budd Chiari syndrome and veno-occlusive disease

Question 7

Describe Hepatic Carcinogenesis?

Answer 7

Recurrent hepatocyte death
- Regeneration
- Cellular hyperplasia-reccurent DNA copying
- A mitogenic environment
Inflammation
- Deregulation cell cycle control- cell survival
- DNA damage- ROS, RNS, adaducts
- A mutogenic environment

Question 8

What causes Hepatic Carcinogenesis?

Answer 8

HBV DNA integration

Question 9

What are the characteristics of compensated cirrhosis?

Answer 9

Clinical normal
Incidental finding
Lab test or imaging abnormalities
Portal Hypertension may be present

Question 10

What are the characteristics of decompensated cirrhosis?

Answer 10

Liver failure
Acute-on-chronic
Infection
Insult
SIRS

End stage Liver disease
Insufficient hepatocytes - “run out of liver”

Question 11

What are the clinical signs of compensated cirrhosis?

Answer 11

Spider naevi
Plamar erythema
clubbing
gynaecomastia
Hepatomegaly(?)
Spleenomegaly
NONE – most common

Question 12

What are the clinical signs of decompensated cirrhosis?

Answer 12

Jaundice
Ascites
Encephalopathy
bruising

Question 13

What are the complications of cirrhosis?

Answer 13

Ascites
Encephalopathy
Variceal bleeding
Liver Failure

Question 14

Describe the treatment of decompensated cirrhosis?

Answer 14

Remove or treat the underlying cause
Look for and treat Infection
The Physiology is not normal: high NaCl retention
Small frequent meals and snacks should be encouraged as this reduces fasting gluconeogenesis and muscle catabolism

Question 15

Describe the pathway that shows how cirrhosis and portal hypertension leads to ascites?

Answer 15

Hepatocellular dysfunction
Increased production of vasodilators 
Splanchnic arteriolar vasodilation
Activation of arterial baroreceptors
Activation of SNS, RAAS, AVP and ET
Renal vasoconstriction and Na and H2O retention

Question 16

Why does fluid gather in the abdomen?

Answer 16

Hydrostatic pressure is highest there

Question 17

What is the treatment of ascites?

Answer 17

Improve underlying liver disease
Look for and treat infection-SBP
Drugs: No NSAIDS, if iv think of sodium load
Reduce salt intake, maintain nutrition
Diuretics- spironolactone first - monitor Us&Es
Paracentsis
TIPSS
Transplantation
STOP DRINKING ALCOHOL

Question 18

How does sodium balance help improve ascites?

Answer 18

input of Na must be less than output

Question 19

What can Ascites paracentsis provoke?

Answer 19

encephalopathy

Hypovolaemia

Question 20

What is the role of Trans-jugular Intra-hepatitc Porto-systemic Shunt (TIPS)?

Answer 20

stops fluid from getting into the abdomen

Question 21

Describe Spontaneous Bacterial Peritonitis (SBP)?

Answer 21

Translocated bacterial infection of ascites
Neutrophil count >250 cells/mm3
Very bad prognosis

Question 22

What is the treatment for SBP?

Answer 22

Urgent
Antibiotics and Alba
Vascular instability-terlipressin
Maintain renal perfusion
HRS development very poor prognosis

Question 23

What may cause Encephalopathy?

Answer 23

Microglial inflamation

Ammonia glutamate/glutamine shuttle

Question 24

How is Encephalopathy diagnosed?

Answer 24

Flap confusion
Any neurology
Alcohol withdrawal

Question 25

How is Encephalopathy treated?

Answer 25

Look for cause-infection, metabolic, drugs, liver failure
Treat it
Lactulose to clear gut/ reduce transit time - Rifaxamin
Maintain nutritional status with small, frequent meal/snack pattern and bedtime CHO
If spontaneous consider transplantation

Question 26

How can varices be prevented?

Answer 26

B-blockers
- Propranolol
- Carvideolol
- Non-selective
Variceal Ligation

Question 27

How is acute varicle bleeding caused?

Answer 27

Resuscitation
Pharmacological therapy
Timing of therapy
Failed therapy
- TIPSS
- Transection/shunt surgery

Question 28

How is acute varicle bleeding treated?

Answer 28

SCLEROTHERAPY
- Effective & longterm
- Intra-variceal
VARICEAL LIGATION
“banding”
Quicker eradication - lower mortality
BALLOON TAMPONADE
last resort - when patient is dying of blood 
TIPSS
low mortality but can cause encephalopathy

Question 29

Can you get a liver transplant in chronic liver disease?

Answer 29

NO

Question 30

What is the criteria for liver transplant based on?

Answer 30

Event based
Liver Function Based
Quality of life Based

Question 31

How is liver transplant waiting list mortality calculated in the UK and US?

Answer 31

UK = UKELD
US = MELD

Question 32

What UKELD Score do you need to be listed for liver transplant?

Answer 32

≥ 49 i.e. 1 year mortality of 9%
unless……
Variant syndrome or HCC

Question 33

Name some variant syndromes?

Answer 33

Diuretic resistant ascites
Hepatopulmonary syndrome
Chronic hepatic encephalopathy
Intractable pruritus
Polycystic liver disease
Familial amyloidosis
Primary hyperlipidaemia