Cirrhosis Flashcards
What happens to the blood supply of the liver when it is cirrhotic?
blockage of the blood flow causing abnormal signalling
What are the normal hepatic and portal vein and hepatic artery pressures?
Hepatic vein pressure = 4 mmHg
Portal vein pressure = 7 mmHg
Hepatic artery pressure = 100 mmHg
During portal hypertension, what may happen to portocaval astamoses?
become engorged, dilated, or varicosed and subsequently rupture
What defines portal hypertension?
Portal vein - Hepatic vein pressure gradient greater than 5 mm Hg
What does portal hypertension result from?
Increased resistance to portal flow (R)
Increased portal venous inflow (Q)
What are the two classes of portal hypertension causes?
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
Describe Hepatic Carcinogenesis?
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
What causes Hepatic Carcinogenesis?
HBV DNA integration
What are the characteristics of compensated cirrhosis?
Clinical normal
Incidental finding
Lab test or imaging abnormalities
Portal Hypertension may be present
What are the characteristics of decompensated cirrhosis?
Liver failure Acute-on-chronic Infection Insult SIRS
End stage Liver disease
Insufficient hepatocytes - “run out of liver”
What are the clinical signs of compensated cirrhosis?
Spider naevi Plamar erythema clubbing gynaecomastia Hepatomegaly(?) Spleenomegaly NONE – most common
What are the clinical signs of decompensated cirrhosis?
Jaundice
Ascites
Encephalopathy
bruising
What are the complications of cirrhosis?
Ascites
Encephalopathy
Variceal bleeding
Liver Failure
Describe the treatment of decompensated cirrhosis?
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
Describe the pathway that shows how cirrhosis and portal hypertension leads to ascites?
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
Why does fluid gather in the abdomen?
Hydrostatic pressure is highest there
What is the treatment of ascites?
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
How does sodium balance help improve ascites?
input of Na must be less than output
What can Ascites paracentsis provoke?
encephalopathy
Hypovolaemia
What is the role of Trans-jugular Intra-hepatitc Porto-systemic Shunt (TIPS)?
stops fluid from getting into the abdomen
Describe Spontaneous Bacterial Peritonitis (SBP)?
Translocated bacterial infection of ascites
Neutrophil count >250 cells/mm3
Very bad prognosis
What is the treatment for SBP?
Urgent Antibiotics and Alba Vascular instability-terlipressin Maintain renal perfusion HRS development very poor prognosis
What may cause Encephalopathy?
Microglial inflamation
Ammonia glutamate/glutamine shuttle
How is Encephalopathy diagnosed?
Flap confusion
Any neurology
Alcohol withdrawal
How is Encephalopathy treated?
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
How can varices be prevented?
B-blockers - Propranolol - Carvideolol - Non-selective Variceal Ligation
How is acute varicle bleeding caused?
Resuscitation Pharmacological therapy Timing of therapy Failed therapy - TIPSS - Transection/shunt surgery
How is acute varicle bleeding treated?
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
Can you get a liver transplant in chronic liver disease?
NO
What is the criteria for liver transplant based on?
Event based
Liver Function Based
Quality of life Based
How is liver transplant waiting list mortality calculated in the UK and US?
UK = UKELD US = MELD
What UKELD Score do you need to be listed for liver transplant?
≥ 49 i.e. 1 year mortality of 9%
unless……
Variant syndrome or HCC
Name some variant syndromes?
Diuretic resistant ascites Hepatopulmonary syndrome Chronic hepatic encephalopathy Intractable pruritus Polycystic liver disease Familial amyloidosis Primary hyperlipidaemia
