cirrhosis Flashcards
1
Q
what is cirrhosis
A
scarring and fibrosis of the liver
- hepatocyte regeneration creating scar tissue
- reversible
2
Q
process of cirrhosis
A
- liver injury
- stellate cells in space of disse activated by cytokines produced by kupffer cells and hepatocytes
- stellate cells-> myofibroblast cell and produce collagen and pro-inflammatory cytokines
- hepatocyte damage and tissue fibrosis
3
Q
causes of cirrhosis
A
- drugs, alcohol: methotrexate
- autoimmune hepatitis
- metabolic: NASH, haemachromatosis
- infective: hepatitis
- wilsons, alpha 1 antitryptin
- vascular: budd-chiari
- biliary: PBC or PSC
4
Q
ranking of main causes of cirrhosis 6
A
- alcohol 50-60%
- viral hepatitis 10-20%
- PBC 5-10%
- cryptogenic
- autoimmune hepatitis
- haemocrhomatosis
5
Q
cirrhosis presentation
A
- abnormal lft
- asymptomatic
- systemic cutaneous signs
- liver failure - jaundice, encepha, acites, sbp, portal hypertension
- hepatocellular carcinoma
6
Q
most common presentation of cirrhosis
A
ascites and jaundice
7
Q
gold standard test for cirrhosis
A
biopsy
8
Q
cutaneous systemic features of cirrhosis
A
palmar erythema clubbing leukonychia dupytrens contractures hepatic flap jaundice spider naevi hepatosplenomegaly ascites xanthelasma rhinophyma parotid swelling cheeks bruising vitiligo gynaecomastia caput medusae hypoglycaemia testicular atrophy paper dollar skin
9
Q
signs of low albumin
A
ascites
leuconychia
10
Q
signs of chronic cirrhosis >6 months
A
paper dollar skin
loss of muscle bulk
catabolic
leukonychia
11
Q
signs of reduced aldosterone clearance in cirrhosis
A
sodium retention (contributes to ascites)
12
Q
sign of reduced oestrogen clearance in cirrhosis
A
loss of body hair
gynaecomastia
13
Q
4 stages of cirrhosis
A
- non cirrhotic: no symptoms- fibrogenesis and angiogenesis reversible
2.compensated, no varices, scar and x-linking HVPG>6 - compensated cirrhosis but varices present, thick scar nodules HVPG >10
4.decompensated cirrhosis, ascites and variceal rupture
irreversible
HVPG >12
14
Q
5 signs of finger clubbing
A
- loss of nail bed angle
- fluctuation of the nail bed
- increased curvature
- drumsticking
- HPOA hypertrophic osteoarthropathy
15
Q
what is HVPG
A
hepatic venous pressure gradient
16
Q
why does HVPG increase
A
architectual changes fibrosis vascular occlusion endothelial dysfunction increased vascular tone
17
Q
investigations for cirrhosis
A
- anaemia (macrocytic)
- thrombocytopaenia
- increased PT
- hyponatraemia
- low urea
- hyperbilirubinaemia
- increased ALT/AST
- USS
- endoscopy for varices or PHG
18
Q
screening process for complications with chronic cirrhosis
A
every 6 months
- uss for splenomegaly
- afp
- doppler portal vein thrombosis
- endoscopy for varices
- fbc: thrombocytopaenia
- fibroscan
19
Q
what 2 test can be done to show fibrosis
A
hyaluronic acid
fibroscan
20
Q
what causes the thrombocytopaenia
A
splenomegaly
21
Q
3 child-pugh score stages
A
1= prothombin 1-4 seconds, alb >35, bilirubin <34, no ascites
2=pt 5-6, 28-24, 35-50, encephalopathy 1-2, mild ascites
3= pt >6, <27, >50, 3-4 moderate-severe ascites
22
Q
drugs to avoid with chronic cirrhosis
A
- NSAIDS- hepatorenal failure and bleeding varices
- ACEI: hepatorenal failure
- codeine: constipation
- Narcotics- constipation
- anxiolytics- constipation
- fibrotics-methotrexate
- NASH-amiodarone
23
Q
8 complications of cirrhosis
A
- ascites
- varices
- hepatorenal syndrome
- spontaneous bacterial peritonitis
- hyponatraemia
- hepatic encephalopathy
- hepatocellular carcinoma
- portal hypertension
24
Q
4 types of varices
A
stomal
rectal
oseophageal
stomach-portal hypertensive gastropathy
25
how to determine prognosis of variceal haemorrhage
varices develop when HPVG is >10mmHg
| varices bleed when HVPG >12mmHg
26
treatment of varices 8
either non-selective beta blocker carvedilol or variceal band ligation
- cyanocrylate glue injection
- ingection of thrombin
- hemospray
- sengstaken blakemore tube
- TIPSS
- surgical
27
prevalence of oseophageal varices in cirrhosis
50%
28
presentation of varices
hypotension
haematemesis
melaena
29
history for varices
- risk factors for chronic liver disease
- recent NSAIDS
- abdominal sepsis/sugery
- pancreatitis
- umbilical vein sepsis
30
treatment of acute variceal bleeding
```
-resuscitation
intubation, high flow o2, iv access,
-terlipressin
-band ligation
-sengstaken-blakemore tube
-davis stent
- TIPSS
```
31
risk of sengstaken-blakemore tube
aspiration
oseophageal perforation
malposition
32
what is tipss
transjugular intrahepatic portosystemic shunt
- uncontrolled or recurrent variceal bleeding
- gastric varices
- refractory ascites
33
what is terlipressin
synthetic analogue of vasopressin
-used in low blood pressure
adverse ischaemic effects
34
treatment of gastric variceal bleeds
- carvedilol
- or thrombin
- cyanocrylate injection of glue
35
prevalence of ascites in cirrhotics and mortality
50-70% develop ascites
| 2 yr mortality 50%
36
what causes ascites in cirrhosis
sodium and water retention
portal hypertension
low albumin
37
what is used to determine the cause of ascites
high serum ascites albumin gradient >11mmol/l due to portal hypertension as means low protein
-but if below cause due to pancreatitis, infection=exudative high protein
38
treatment of cirrhotic ascites
1.sodium restritcion and diuretics
-no added salt (90mmol/l)
-spironalactone (aldosterone antagonist) and furosemide (100:40)
2.large volume paracentesis
(removal fluid >5l), fast response, high rate recurrence
39
diuretic dosage for ascites and complications
maximum
spironalactone 400mg
furosemide 160mg
complications
- electrolytes
- aki
- encephalopathy
- painful gynaecomastia
40
2 definitions of refractory ascites
1. lack of response (<1.5kg weight loss/week) to high dose diurectics and low sodium diet
2. frequent ascites recurrence after therapeutics large volume paracentesis
41
treatment options for refractory ascites
repeated LVP (+albumin)
TIPSS
liver transplantation
42
name given for patients who cannot tolerate diuretics due to the development of complications
diuretic intractable ascites
43
2 main complications of ascites
AKI
-vasodilation from sepsis
-or vasoconstriction from hepatorenal syndrome
hepatorenal syndrome
44
how does liver disease cause hrs
- diuretics use for ascites
- low grade renal hypoperfusion
- spontaneous bacterial peritonitis
- other infections
- gi bleeding
- circulatory dusfunction
45
what is hepatorenal syndrome
splanchnic vasodilation causes hormonal imblanace
-VASOCONSTRICT at kidneys and impaired renal failure
due to poor arterial circulation due to liver disease
-toxins build up in the body
46
type 1 vs type 2 hrs
type 1= rapid progressive kidney failure creatinine >221
type 2=slower onset and progression
creatinine >133= better prognosis median survival 6 months
47
how does liver failure affect kidney function
- fibrosis means less blood gets through
- macula densa receives less sodium
- constrict in efferent and relax in afferent
- increase renin release from juxtag cells
- overall get VASOCONSTRICTION
48
HRS-AKI diagnosis criteria
- dx of cirrhosis and ascties
- dx of aki
- no response after 2 consecutive days of diuretic withdrawal and plasma volume expansion with albumin 1g per kg
- abscence of shock
- no recurrent or recent use of nephrotoxic drugs (nsaids)
- no macroscopic signs of structural kidney injury ie no proteinuria
49
what level should ascites be brought down by
0.5kg/ weight loss a day
50
prognosis of HRS 1 AND 2
hrs 1=2 week mortality rate 80%
| hrs 2= median 6 months
51
Treatment type 1 HRS
-terlipressin with albumin
52
prevention of HRS 4
- antibiotics during acute variceal haemorrhage
- albumin during SBP
- avoid beta blockers in therapeutic window
- earlier detection
53
treatment of AKI 1
remove risk factors
- nephrotoxic durgs
- vasodilators
- nsaids
- diuretics
- treat infections
54
treatment of AKI 2 and 3
- stop diuretics
- volume expansion with albumin
- if HRS also give Terlipressin (vasoconstrict)
55
diagnosis of spontaneous bacterial peritonitis
ascitic fluid PMN count >250 cells per mm3
| often e.coli
56
prevalence in ascitic patients
10-30%
57
symptoms of sbp 4
abdominal pain
rebound tenderness
absent bowel sounds
fever
58
mortality sbp
20%
59
treatment of sbp
albumin
3rd generation cephalosporins
or
penicillins and metronidazole (vancomycin)
60
long term prophylaxis for sbp
norfloxacin
61
treatment for hypervolaemic hyponatraemia in cirrhosis
tolvaptan-oral v2 antagonist increases free water excretion
62
pathophysiology of hyponatraemia in cirrhosis
- liver disease get water and sodium retention to overcome low blood pressure systemically
- leads to impairment of kidneys to eliminate solute free water
63
path of hepatic encephalopathy
accumulation of gut derived neurotoxic substances eg ammonia, astrocyte damage, impaired neurotransmitters
64
dx of hepatic encephalopathy
blood ammonia
ecg
critical flicker freq
flapping tremor
65
management of hepatic encephalopathy
- give lactulose
- check constipation
- monitoring
- TIPSS
- Diuretics
- maintains fluids
- fall precaution
- avoid cns depressants
- consider prophylactic intubation for grade 3/4
66
how does lactulose work
- laxative
- cathartic (reduces colonic bacterial load)
- acidifies gut lumen bacteria
- inhibits ammoniagenic bacteria
67
second line drug for hepatic encephalopathy
Rifaximin 400mg (gut sterilisation-antibiotic)
68
grading of hepatic encephalopathy
1=sleep reversal so restless
2=drowsy,lethargic
3=sleepy and confused
4=coma
69
hepatocellular carcinoma causes
nafld
| viral hepatitis
70
screening for HCC
afp and uss every 6 months
71
diff dx for HCC
```
metastasis
cholangiocarcinoma
haemangioa
adenoma
cyst
abscess
```
72
CT characteristics of HCC 3 stages
arterial phase (enhancement)
portal venous phase (washout)
portal vein thrombosis
73
treatment options for HCC and size of nodules criteria
also success rate
-resection-possibly curative
-transplantation
single tumour <5cm or <3 nodules <3cm
-percutaneous ablation
radiofrequency ablation,ethanol
-transarterial chemotherapy TACE, delays regression often need repeating
74
drug used for hcc chemotherapy
sorafenib
75
function of albumin and why should it be used in treating decompensated cirrhosis
- 70% of total plasma oncotic activity
- high capacity molecule transport
- free radical scavenging
- capillary permeability effect
- neutrophil adhesion effect
- nitric oxide binding
- drug binding
- improves renal blood flow and autoregulation in cirrhosis and aki
76
What is haemochromatosis
High iron blood due to hfe gene
77
What is wilsons
High copper due to low carrier ceruloplasmin
78
What is alpha 1 antitrypsin
Deficiency in alpha 1 means liver produces large amounts of abnormal alpha 1 protein which clogs up liver
Or can't secrete normal protein properly
79
What is Budd chiari
Thrombosis of hepatic artery usually due to mutation in clotting like jak 2
80
7 drugs to avoid in cirrhosis
```
NSAIDS
ACEI
codeine
narcotics
anxiolytics
methotrexate in fibrosis
amiodarone in nash
```
