Cirrhosis Flashcards
pathology
chronic inflammation -> fibrosis. nodules of scar tissue from within liver
this causes resistance which can lead to portal hypertension
4 most common causes of cirrhosis
alc liver disease
NAFLD
hep b
hep c
rarer causes of cirrhosis (BC that important as some are potentially reversible
haematochromatosis wilson's PBC alpha 1 antitrypsin deficiency autoimmune hepatitis cystic fibrosis drugs
what drugs can cause cirrhosis
amiodarone
methotrexate
sodium valproate
symptoms of cirrhosis (NB same as any other liver disease + one extra due to portal HTN)
jaundice hepatomegaly spider naevi palmar erythema gynaecomastia bruising (due to abnormal clotting) ascites caput medusae flapping tremor \+splenomegaly due to portal hypertension
what will LFTs show
often normal
AST > ALT is seen in cirrhosis
bilirubin may be raised
what may happen to albumin
hypoauminaemia (liver usually produces this but can’t)
when may there be hyponatraemia
fluid retention in severe disease
how is HCC screened for and how often
alpha fetoprotein + USS
every 6 months
what test can be used for assessing firbosis in NAFLD (NB not used everywhere bc of availability)
enhanced liver fibrosis (ELF) test
what may abdo USS show
liver nodularity cockscrew appearance of arteries with increased flow as they compensate for reduced portal flow enlarged portal vein with reduced flow ascites splenomegaly
what scan is done every 2 years in pts at risk of cirrhosis
fibro scan (used to test elasticity of the liver)
what score is used to indicated severity and prognosis in cirrhosis
child-pugh score
assesses bilirubin, albumin, INR, ascites, encephalopathy
what score is used every 6 months for pts with compensated cirrhosis to predict prognosis and guide referral for liver transplant
MELD score
sum up the general management for someone with cirrhosis (of any cause)
USS and alpha fetoprotein every 6 months for HCC screening
endoscopy every 3 years in pts without known varices
high protein, low sodium diet
MELD score every 6 months
consider liver transplant
how often should endoscopy be done to screen for varices
every 4 years
complications of cirrhosis
malnutrition + muscle wasting portal hypertension varices + bleeding ascites and SBP hepatoreanl syndrome hepatic encephalopathy heaptocellular carcinoma
how to manage malnutrition
regular meals every 2-3 hours
low sodium (to minimise fluid retention)
high protein, high calorie
avoid alco
how do varices occur
high pressure causes back pressure into portal system causing vessels where the portal system joins the systemic venous system to become swollen and tortuous
where do varices occur
gastrooesophageal junction
ileocaecal junction
rectum
anterior abdo wall via umbilical vein (caput medusae)
why are varices problematic
not until they start bleeding - pt can bleed out (exsanguinate) v quickly
rx of stable varices
propranolol (reduces portal HTN)
elastic band ligation
injection of scelrosant (but less effective than ligation)
TIPS
what is TIPS
Transjugular Intra-hepatic Portosystemic Shunt (TIPS) - wire under xray guidance into the jugular vein, down the vena cava and into the liver via the hepatic vein. Connection between hepatic vein and portal vein with. allows blood to flow directly through to relive pressure in portal system and on varices. This is used if medical and endoscopic treatment of varices fail or if there are bleeding varices that cannot be controlled in other ways.
treatment of bleeding oesphageal varices
resus: vasopressin analgoues to cause vasoconstriction reduce bleeding. prophylactic abx (shown to reduce mortality). consider ITU and intensive care
urgent endoscopy: inject sclerosant OR elastic band ligation.
sengstaken-blakemore tube if endoscopy fails (inflatable tube used to tamponade bleed.
how does ascites occur in cirrhosis
fluid leaks out of capillaries because of high pressure in portal system
is fluid transudate or exudate in ascites from cirrhosis
transudate
rx ascictes
low sodium diet sprinolacftone paracentesis (ascitic tap or drain) prophylacftic abx agains SBP consider TIPS/transplantation if ascites is refractive.
most common organisms in SBP
e coli
klebsiella
gram +ve cocci (staph/enterococcus)
rx SBP
IV cephalosporin e.g. cefotaxime
is hepatorenal syndrome fatal and what is the rx?
yes fatal within 1 week unless liver transplant is performed
what causes hepatic encephalopathy
build up of toxins that affect brain, particularly ammonia (produced by intestinal bacteria when breaking down protein, absorbed into blood from gut)
presentation of hepatic encephalopathy
acute: reduced conciousness and confusion
chronic: changes to personality, memory and mood
precipitating factors of hepatic encephalopathy
constipation electrolyte disturbance infection GI bleed meds high protein diet
rx hepatic encephalopathy
laxatives to promote amonia excretion
abx (rifaximin) to reduce number of intestinal bacteria producing ammonia
what is fulminant hepatic failure
liver failure that takes place within 8 weeks of onset of underlying illness
what are the four things that suggest liver failure
hepatic encephalopathy
abnormal bleeding (bc clotting factors are messed up)
ascities
jaundice
best marker of deteriorating liver function
INR (from PT)
what is septic shock
sepsis + bot of persistant hypotension requiring vasopressors to maintain MPA>65 lactate>2
what score is used to track a person’s status during stay in ICU to determine the extent of organ dysfunction/rate of failure
SOFA score (sequential organ failure assessment score)
both mean and highest SOFA scores predictors of outcome
