Cirrhosis and Complications Flashcards
Overview of Portal Circulation
- In cirrhosis: liver is hard 2/2 fibrosis and circulatory factors triggers vasoconstriction.
- Blood which should enter liver from portal vein instead backs up into varices. This is a high pressure process, lymphatics cannot compensate, and ascites then develops.
Cirrhosis Pathophysiology.
- Pressure = flow x resistance.
- Cirrhosis causes increased mechanical resistance to portal flow, thus increased portal pressures.
- Intrahepatic vascular resistance is affected by decrease in vasodilators and increase in vasoconstrictors.
- Vasocactive substances causes decreased splanchnic arteriolar resistance which increases portal flow and further increases portal pressure; splanchnic circulation is also increased by hyper dynamic circulation
- Increased Na+ retention leads to increased vascular volume.
3 levels of portal hypertension
- Pre-sinusoidal (no liver disease): portal vein obstruction.
- Sinusoidal (intrinsic liver disease is present): Cirrhosis, infiltrative disease.
- Post sinusoidal: Blood cannot get out of the liver: Budd-Chiari syndrome, constrictive pericarditis.
Portal vein-> Sinusoidal-> Hepatic Vein
Extra (pre)hepatic portal HTN
- Portal Vein thrombosis
- Anatomical obstruction of portal vein (tumor)
- AV fistula
Intahepatic portal HTN: Cirrhosis
- Hepatocellular disease: hepatitis (can lead to cirrhosis)
- Biliary disease: BA, PSC (can lead to cirrhosis).
- Vascular disease: Nodular regenerative hyperplasia (NRH), Sinusoidal obstruction syndrome (SOS). occurs after chemo/radiation.
- Fibrosis: congenital hepatic fibrosis. (a/w polycystic kidney)
- Other
anastomosing pattern of bile ducts in broad band of fibrosis is seen in congenital hepatic fibrosis.
Nodular Regenerative Hyperplasia: nodules pressing on vessels
Post hepatic causes of portal HTN: when blood cannot exit the liver. centrilobular necrosis from lack of blood outflow.
Budd Chiari
HV thrombosis or IVC thrombosis
Pericardititis (restrictive)
R-sided heart failure
Diagnosis of portal HTN
-PE: splenomegaly, ascites
- thrombocytopenia, leukopenia
- US: increased echo texture of cirrhotic liver, ascites, splenomegaly, reversal of portal vein flow
- EGD: vases, portal HTN gastropathy
- HVPG: Difference between wedged hepatic venous pressure (shows portal vein pressure) and free hepatic vein pressure. HVPG>12 is associated with varices and ascites.
Ascites: physiology
- Vasodilation and effective hypovolemia result in stimulation the RAAS, salt and water are retained.
- Portal HTN increases hydrostatic pressure in splanchnic circulation, exceeding capacity of lymphatics
- Low albumin decreases colloid oncotic pressure, allowing fluid to leak into interstitium
DDX of ascites
- Hepatic: cirrhosis or severe hepatitis or ALF
- Circulatory: Right heart failure or Budd- Chiara syndrome
- Cancer
- Inflammatory: pancreatitis
- Renal/proteinuria: nephrotic syndrome.
- Infectious: TB or bacterial peritonitis
- Mixed: cirrhosis + secondary etiology
- Myxedema ascites (hypothyroidism)
Evaluation of Ascites
- PMN count >250/cc3 indicates SBP
- Culture
- Protein/glucose: High serum-ascites albumin gradient >1.1 is seen in chronic liver disease
- LDH
- Amylase
Ascites in liver disease has low protein content
- High serum-ascites albumin gradient >1.1 g/dl is seen in chronic liver disease
SBP
- Definition: infection of ascites fluid
- Sis: fever, and pain, non-specific worsening
- Dx: PMN>250/cc3, +culture
- Bugs: pneumococcus, gram-negative rods
- Tx: IV abx,
- Prevention: PO antibiotics
Management of Ascites in Cirrhosis
- Mild Na restriction
- Diuretics: spironolactone (inhibits aldosterone (acts distally): 2-3mc/kig/d)
Lasix: loop diuretic: 1-2mg/kg/d
-Albumin inclusion: 1g/kg of 25% albumin +lasix - Paracentesis +/- albumin
- TIPS
Variceal Bleeding
- RF: spleen size, plt count, liver synthetic function
- Management: acute resuscitation, correct coagulation, antibiotics, PPI prophylaxis, Octreotide (vasoactive), EGD: EBL: sclerotherapy, ?cyanoacrylate for gastric varies.
-Shunts: TIPS, surgical, transplant.
REX shunt: used for extra-hepatic portal HTN
Mesenteric vein to coral vein shunt, restores anterograde flow through liver in extra hepatic portal vein obstruction.
- only used for patient with portal vein thrombosis
Hepatopulmonary syndrome vs
Portopulmonary HTN
- HPS, tiny shunts develop within the lung: SOB, digital clubbing, diagnostic testing: bubble echo with R to L shunting of bubbles within 3-5 beats. Management: transplant.
- PPH: fatigue, chest pain, SOB. Diagnostic etsting: cardiac Cath with measurements. Management: transplant is contraindicated when pressures are very high.
Hepatorenal Syndrome
- Compensated cirrhosis: splanchnic vasodilation, low effective arteriolar blood volume, and heart compensates
vs - Decompensated cirrhosis: splanchnic vasodilation, RAAS actives, kidneys vasoconstriction, hepatorenal syndrome
Hepatorenal syndrome
- renal dysfunction, kidney is vasoconstrictor.
DDX: pre renal, ATN, intrinsic kidney disease
Management: fluid management, bolus trial, avoid intravascular volume depletion, NSAIDS, ahminoglycosides - Vasoactive drugs/albumin, octreotide
HRS resolves after liver transplantation, consider kidney transplant if dialysis for >2 months
Hyponatremia
Cirrosis/portal HTN -> splanchnic/systemic vasodilation, -> decreased effective arterial blood volume –> activation of neurohumoral systems –> renal tubule/water retention –> dilution hyponatremia
Portosystemic Encephalopathy
- build up of ammonia, can be seen in advanced liver disease, precipitated by bleed, infection, drugs.
- Tx: lactulose, Rifaximin, Flagyl
