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yr 3 GI > cirrhosis > Flashcards

cirrhosis Flashcards

1
Q

definition of cirrhosis

A

end stage of chronic liver damage

replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes

decompensated when complications: ascites, jaundie, encephalopathy, or GI bleeding

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2
Q

aetiology of cirrhosis

A

chronic alcohol misuse - most common UK cause

chronic viral hep - hep B/C most common worldwide cause

autoimmune hep

drugs - methotrexate, hepatotoxic drugs, amiodarone, methyldopa

inherited

vascular -budd-chiari syndrome or hepatic venous congestion

chronic biliary diseases

cryptogenic - 5-10%

NASH

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3
Q

inherited conditions that cause cirrhosis

A

a1-antitrypsin deficiency

haemochromatosis

wilson’s disease

galactosaemia

CF

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4
Q

chronic biliary diseases that cause cirrhosis

A

PBC

PSC

biliary atresia

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5
Q

Non-alcoholic steatohepatitis and cirrhosis

A

increases risk of developing cirrhosis

NASH is associated with:

  • obesity
  • dm
  • TPN
  • short bowel syndromes
  • hyperlipidaemia
  • drugs - amiodarone, tamoxifen
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6
Q

precipitatants for cirrhosis decompensation

A

infection

GI bleeding

constipation

high-protein meal

electrolyte imbalances

alcohol and drugs

tumour development

portal vein thrombosis

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7
Q

epidemiology of cirrhosis

A

among top 10 leading causes of death worldwide

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8
Q

sx of cirrhosis

A

early non-specific:

  • anorexia
  • nausea
  • fatigue
  • weakness
  • weight loss

s caused hy reduced liver synthetic function

sx caused by reduced detoxification function

sx of portal HTN

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9
Q

cirrhosis sx caused by reduced liver synthetic function

A

easy bruising

abdo swelling

ankle oedema

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10
Q

sx of cirrhosis caused by reduced detoxification function

A

jaundice

personality change

altered sleep pattern

amenorrhoea

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11
Q

sx of cirrhosis caused by portal HTN

A

abdo swelling

haematemesis

PR bleeding/melaena

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12
Q

signs of cirrhosis

A
  • stigmata of chronic liver disease: asterixis, bruises, clubbing, dupuytren’s contracture, erythema
  • jaundice
  • gynaecomastia
  • atrophic testes
  • loss of body hair
  • leukonychia
  • Terry’s nails - white proximally, distal 1/3 red from telangiectasia
  • parotid enlargement (alcohol)
  • spider naevi
  • scratch marks
  • ascites - shifting dullness and fluid thrill
  • hepatomegaly - small and shrunken in later stage
  • testicular atrophy
  • caput medusae
  • splenomegaly - portal HTN
  • hyperdynamic circulation
  • xanthelasma
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13
Q

Ix for cirrhosis

A

bloods

to determine the cause

ascitic tap

liver biopsy

imaging

endoscopy - examine for varices, portal hypertensive gastropathy

child-pugh grading

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14
Q

bloods for cirrhosis

A

FBC - low Hb, low WCC and plt - hypersplenism

LFT - may be normal, or - high transaminases, ALP, GGT, BR, low albumin

clotting - prolonged PT (reduced synth of clotting factors)

serum AFP - high in chronic liver disease, V high suggest hepatocellular ca

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15
Q

ix to determine the cause of cirrhosis

A

viral serology - HBsAg, HBsAb, HCV Ab

immunoglobins

a1-antitrypsin

caeruloplasmin - wilson’s

iron studies - serum ferritin, iron, total iron binding capacity - haemochromatosis

antimitochondrial Ab - PBC

ANA

SMA - autoimmune hep

a-fetoprotein

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16
Q

ascitic tap - cirrhosis

A

MC&S

biochem - protein, albumin, glucose, amylase

cytology

if neutrophils >250/mm3 - indicates spontaneous bacterial peritonitis

17
Q

liver biopsy - cirrhosis

A

percutaneous or transjugular if clotting deranged or ascites present

histopath:

  • periportal fibrosis
  • loss of normal liver architecture
  • nodular

grade - assessment of degree of inflammation

stage - degree of architectural distortion - from mild portal fibrosis -> cirrhosis

18
Q

imaging for cirrhosis

A

US, CT, MRI

to detect complications: ascites, hepatocellular ca, hepatic or portal vein thrombosis

to exclude biliary obstruction

MRCP if PSC suspected

19
Q

US and duplex for cirrhosis

A

small/large liver

splenomegaly

focal liver lesions

hepatic vein thrombus

reversed flow in portal vein

ascites

20
Q

MRI for cirrhosis

A

increased caudate lobe size

smaller islands of regenerating nodules

presence of right posterior hepatic notch

all more in alcoholic than viral

21
Q

child-pugh grading - cirrhosis

A

class A - 5-6

class B - 7-9

class C - 10-15

22
Q

Mx of cirrhosis

A

treat the cause if possible

avoid alcohol, sedatives, opiates, NSAIDs and drugs that effect the liver

cholestyramine - help pruritis

nutrition is important - if intake is poor need dietition review and enteral supplements

NG feeding might be needed

high dose ursodeoxycholic acid in PBC - may imporve LFT and transplant free survival

penacillamine for wilsons

23
Q

complications of cirrhosis

A

Portal HTN with ascites

encephalopathy or variceal haemorrhage

SBP

hepatocellular ca

renal failure - hepatorenal syndrome

pul HTN - hepatopulmonary syndrome

coagulopathy

hypoalbuminaemia - oedema

sepsis - pneumonia, septicaemia

hypoglycaemia

HCC increased risk

24
Q

Mx for encephalopathy complication of cirrhosis

A

treat infections

exclude GI bleed

lactulose

phosphate enemas

avoid sedation

prophylactic lactulose and rifaximin

25
Q

Mx of ascites complication of cirrhosis

A

diuretics - spirinolactone +- furosemide

sprinolactone counters deranged RAAS system

dietary Na restriction 88meq or 2g/day

therapeutic paracentesis - human albumin replavement IV

monitor weight daily

fluid restriction in pts with plasma Na <120mmol/L

avoid alcohol and NSAIDs

chart daily weight and aim for weight loss 0.5kg/day

26
Q

Mx of spontaneous bacterial peritonitis (SBP) complication of cirrhosis

A

considered in any pt with ascites that deteroirates quickly - may be asymptomatic

AB - cefuroxime and metronidazole

prophylaxis against recurrent SBP with ciprofloxacin for high risk pts (low albumin, high PT/INR, low ascitic albumin), or if had previous episode

common organisms - E coli, klebsiella, streptococci

27
Q

surgical Mx of complications of cirrhosis

A

consider TIPS to relieve portal HTN of recurrent variceal bleeds or diuretic-resistant ascites

  • may precipitate encephalopathy

liver transplant is only cure

28
Q

Px of cirrhosis

A

depends on the aetiology and complications

generally poor - 5yr surival 50%

if ascites 2yr survival 50%

Poor prognostic indicators: encephalopathy; serum Na+ <110mmol/L; serum albumin <25g/L; high INR.

29
Q

what is hepatorenal syndrome

A

cirrhosis + ascitis + renal failure - if other causes of renal failure have been excluded

abnormal haemodynamics -> splanchnic and systemic vasodilation, but renal vasoconstriction

bacterial translocation, cytokines and mesentaric angiogenesis -> splanchnic vasodilation, and altered renal autoregulation is involved in renal vasoconstriction

30
Q

complications of cirrhosis caused by portal HTN

A

ascites

splenomegaly

portosystemic shunt includinhg oesophageal varices +- life threatening upper GI bleed

caput medusae

31
Q

follow up Mx of cirrhosis

A

consider US +- a-fetoprotein every 6mo to screen for HCC - when that info would change mx

32
Q

how does cirrhosis cause renal failure

A

reduced hepatic clearance of immune complexes = trapping in kidneys (=IgA nephropathy +- hepatic glomerulosclerosis

yr 3 GI (52 decks)

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