Cirrhosis Flashcards
Aetiology? 4 most common
- Alcoholic liver disease
- NAFLD
- Hep B
- Hep C
Signs?
as per alcoholic liver disease:
- Jaundice
- HSM
- Caput medusae
- Ascites
- Palmar erythema
- Spider naevi
- Gynaecomastia –> due to endocrine dysfunction
- Asterixis
- Bruising
Ix?
- Bloods
- Glucose
- PT raised
- Albumin low
- FBC
- U&E
- deranged in hepatorenal syndrome
- hyponatraemia
- LFTs
- in decompensated, all markers deranged
- if cause unknown:
- viral markers & auto-antibodies
- Enhanced Liver Fibrosis (ELF) blood test 1st line in assessing fibrosis in NAFLD
- US
- FibroScan
- Endoscopy
- CT/MRI
- Liver biopsy
what changes may be seen on US?
- nodularity of liver surface
- “corkscrew appearance” of hepatic arteries
- enlarged portal vein w reduced flow
- ascites
- splenomegaly
how do you determine prognosis?
Child-Pugh score
Mx?
- Screening for hepatocellular carcinoma - US & alpha fetoprotein every 6 months
- Endoscopy every 3 years in pts without known varices
- High protein, low sodium diet
- Liver transplant
- Manage complications
Complications?
- malnutrition
- portal HT, varices & variceal bleeding
- ascites & spontaneous bacterial peritonitis
- hepatorenal syndrome
- hepatocellular carcinoma
- hepatic encephalopathy
what are varices?
swollen, tortuous vessels that occur at junction between portal system and systemic venous system:
- gastro-oesophageal junction
- ileocaecal junction
- rectum
- anterior abdo wall (caput medusae)
Mx of varices?
if varices stable - bleed prevention:
- beta blockers
- endoscopic ligation
- TIPS
- used if medical and endoscopic treatment fails
- makes connection between hepatic vein and portal vein, allowing blood to flow directly from portal vein to hepatic vein bypassing liver
- surveillance by endoscopy
Pathophysiology of Ascites?
- low oncotic pressure (low albumin) & increased pressure in portal system causes increased capillary permeability & fluid to leak out into peritoneal cavity
- this causes drop in circulating blood volume = low BP= RAAS kicks in
what kind of ascites does cirrhosis cause?
transudative (low protein content)
Ix of ascites?
paracentesis (ascitic tap) & send for protein, cell count, microscopy / culture, cytology
pathophysiology of hyponatraemia in ascites
dilutional hyponatraemia due to ADH response in kidneys
Mx of ascites?
- low sodium diet
- anti-aldosterone diuretics ie spironolactone
- prophylactic abx against SBP
- consider TIPS
- consider liver transplant
Epidemiology of SBP
- occurs in around 10% of pts w ascites secondary to cirrhosis
- infection develops in ascitic fluid with no clear cause
presentation of SBP?
- Can be asymptomatic
- Fever
- Abdo pain / tenderness
- Deranged bloods
- Ileus (reduced movement in intestines)
- Hypotension
most common organisms for SBP?
- E.Coli
- Klebsiella pneumoniae
- Gram positive cocci
Mx of SBP?
Ascitic culture prior to giving Abx:
- IV Cephalosporin ie Cefotaxime
pathophysiology of hepatorenal syndrome?
RAAS activation –> renal vasoconstriction –> starvation of blood to kidneys –> fatal within a week or so unless liver transplant performed
PATHOPHYSIOLOGY OF hepatic encephalopathy?
- Gut bacteria break down product = ammonia
- Ammonia absorbed into blood stream and usually goes to liver where broken down into harmless waste product.
- In cirrhosis, not able to do this and therefore build- up of ammonia. It also bypasses liver and goes directly into systemic circulation.
- Presentation:
- Acutely–> confusion & reduced consciousness
- Chronically –> changes to personality, memory and mood
Mx of hepatic encephalopathy?
laxatives (excretion of ammonia) & Abx (reduce gut bacteria)
