Cirrhosis Flashcards
Differential diagnosis of Cirrhosis?
- Alcoholism
- Chronic Viral Hepatitis (B,C)
- Non-alcohlic statohepatitis (NASH) due to obesity epidemic
- now, most common cause in use due to obesity epidemic
- Biliary Cirrhosis
- primary biliary cirrhosis (PBC)
- Primary Sclerosing Cholangiitis (PSC)
- Auotimmune cholangiopathy
- Cardiac Cirrhosis
- Inherited Metabolic Liver diseases
- heriditary hemochromatosis
- Wilson’s disease
- Alpha-1-antitrypsin deficiency
- cystic fibrosis
- rare disorders
- porphyria, urea cycle defects, etc.
- cryptogenic cirrhosis
- we don’t have any idea why they have it
- Drugs
- methotrexate
- isoniazid
- alpha-methyldopa
- vitamin A
- amiodarone
- Weird stuff
- brucellosis
- echinococcosis
- congenital or tertiary syphilis
- indian childhood cirrhosis
- granulomatous liver disease
- polycystic liver disease
- schistosomiasis (presinusoidal fibrosis)
- acute fatty liver of pregnancy
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Areas with what tyep of innervation are more susecptible to vascular complications?
vascular complications tend to localize around areas of dual circulation and dual venosu drainage
where portal venous circulation in close proximity to systemic circulation – shared areas can expeience hypertension & varicosities will form
Complications of Cirrhosis?
- anascarca = genera swelling of whole body
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How do ascites happen?
What are 3 factors that lead to it?
Increased hydrostatic pressure in the mesenteric circulation resulting in serous effusion (fluid) into the serosa resulting in aggregation of fluid in the peritoneum
- hydrostatic pressure from the cirrhosis causing portal venous hypertension
- part due to decreased circulating plasma protein
- in part due to vasodilation in
this leads to activation fo vasoconstrictors–> leads to sodium retention–> edema
Differential diagnosis of ascites?
What tests are performed every time you do a pericentisis?
- glucose
- if you think its peritonitis
- lower glucose & simultaneous glucose in serum would indicate bacterial consumption of glucose in fluid
- LDH
- infectious stuff
- amylase
- pancreatitis
- cytology
- if suspect cancer
- triglycerides
- if mesenteric lymphpatic link
- bilirubin
- if damage to biliary tree
Why is ascites concerning?
- risk spontaneous bacterial peritonitis
- protein rich fluid – outstanding culture media
- rough to get antibiotics to the site
- hernia formation
- fluid leakage – impaired healing
- abdominal compartment syndrome
- can occlude venous return
- ileus
- functional equivalent bowel obstruction (bowel goest on strike)
- SAAG >= 1.1 indicates portal hypertension with 97% accuracy
- serum albumin ascites gradient
How do you treat ascites?
Why can’t you just drain it?
If you just drain it, it will keep coming back
- dietary sodium restriction
- <2000 mgday
- education
- constant reinforcement
- dieuretics (get kidney to restrict sodium)
- spironalactone
- furosemide
- 100:40 ratio
- can titrate every 2 weeks
- occasional paracentesis
- when diuretics don’t work well enough
- at admition to hospital or symptomatic control abdominal distention
- need to give 5g albumin/liter you remove
- serial therapeutic paracentesis
- TIPS
- long catheter through jugular into superior vena cava into inferior vena cava into hepatic vein radical & shoeve a needle through wall to portal vein. Creating a tunnel through hepatic portal vein & hepatic systemic vein so portal venous drain can decombress.
- without going through hepatic first pass metabolism
- liver transplant
What structure leaks to cause ascites?
- capillary driven
- coming from gut, omentum, other serosa surface
What are the most common varices?
Specific risks?
Treatment?
Esophageal varices
- high bleeding risk
- treatment
- banding
- sclerotherapy injections
- propanolol or nadolol (no selective beta blockers) - reduce portal venous pressure
How are gastric varices treated?
- cyanoacrylate
- splenectomy
- remove circulation through short gastric
How does hepatic encephalopathy occur?
- Urea splitting organisms in the GI flora produce ammonia
- normally protal circulation first pases nitrogenous waste through the liver
- hepatocytes process it via the urea
- ammonia will diffuse intot he CNS
- astrocytes use ammonia to make glutamate from glutamine (a cytotoxin)
- benzodiazepine-like effect (GABA mediated)
- unabated, in the increased CNS edema can cause herniation
At what westhave critera do astrices start showing up & disappearing?
grade 2 – major risk factor for automobile accidents
disappear grade 3/4
