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Junior Medicine- GI > Cirrhosis And Portal HTN > Flashcards

Cirrhosis And Portal HTN Flashcards

1
Q

How does cirrhosis occur?

A

1- Chronic inflammation and damage to the liver cells

2- Liver cells replaced with scar tissue

3- Nodules form

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2
Q

What does the fibrosis cause?

A

1- Affects blood flow through the liver

2- Increased resistance in the portal system

3- Portal HTN

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3
Q

Outline the Portal Venous System.

A
  • SMV
  • IMV and Splenic Vein combined
  • Left Gastric Vein
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4
Q

What are the four most common causes of cirrhosis?

A

BANC

  • Hep B
  • ALD
  • NAFLD
  • Hep C
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5
Q

What paediatric condition can cause cirrhosis?

A

CF

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6
Q

Which drugs can cause cirrhosis?

A
  • Amiodarone
  • Methotrexate
  • Sodium Valproate

…

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7
Q

What signs might be seen in cirrhosis?

Hands round to abdomen

A
  • Palmar erythema
  • Asterixis
  • Bruising (abnormal clotting)
  • Jaundice
  • Spider Naevi
  • Gynaecomastia
  • Ascites
  • Caput Medusa
  • Hepatomegalysplenomegaly
  • Shrunken, nodular liver
  • Testicle atrophy
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8
Q

What bloods would you do in cirrhosis?

A
  • LFTs
  • Clotting
  • UsEs
  • Enhanced liver fibrosis test (ELF)
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9
Q

What is the limitation of the ELF test?

A

Only detects cirrhosis in NAFLD

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10
Q

How does the ELF test work?

A

Uses three markers to grade the fibrosis from mild (<7.7) to severe (9.8+)

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11
Q

What will LFTs show in decompensated cirrhosis?

A

Derangement of ALT, AST, ALP and bilirubin

Low albumin

High GGT

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12
Q

What will clotting studies show?

A

Prolonged PTT (clotting factors not made effectively)

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13
Q

What might UsEs show?

A
  • Hyponatraemia (fluid retention)

- Ur and Cr deranged (hepatorenal syndrome)

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14
Q

What tumour marker is essential in cirrhosis?

A

Alpha-fetoprotein

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15
Q

What does alpha-fetoprotein indicate?

A

Hepatocelllular carcinoma

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16
Q

How frequently should AFP be done in cirrhosis patients?

A

6 monthly

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17
Q

What imaging is used in cirrhosis?

A
  • USS

- FibroScan

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18
Q

What does USS scan show in cirrhosis?

A
  • Nodular, shrunken liver
  • ‘Corkscrew’ hepatic arteries with increased flow to compensate for reduced portal flow
  • Enlarged portal vein
  • Splenomegaly
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19
Q

How often should USS be done in cirrhosis patients?

A

6 monthly

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20
Q

Why should cirrhosis patients be screened with USS?

A

For hepatocellular carcinoma

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21
Q

How often should FibroScan (Transient Elastography) be done in patients at risk of cirrhosis?

A

2-yearly

Yearly in Hep B

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22
Q

Why is an OGD useful?

A

To look for varices

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23
Q

How is a cirrhosis diagnosis confirmed?

A

Liver biopsy

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24
Q

How is prognosis indicated in cirrhosis?

A

Child-Pugh Score

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25
Q

What does the Child-Pugh score use?

A
  • Bilirubin
  • Albumin
  • INR
  • Ascites
  • Encephalopathy
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26
Q

What’s the minimum and maximum Child-Pugh score?

A

5-15

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27
Q

What score is used for 3-month mortality in compensated cirrhosis?

A

MELD Score

28
Q

How often should a MELD score be done?

A

6 months

29
Q

What tests should be done every 6 months in cirrhosis?

A
  • MELD Score
  • USS
  • Alpha Fetoprotein
30
Q

How often should an OGD be done in cirrhosis?

A

Every 3 years

31
Q

What diet should be used in cirrhosis?

A

High protein, low sodium

32
Q

What surgery may be used in cirrhosis?

A

Transplant

33
Q

What are the complications of cirrhosis?

A
  • Malnutrition
  • Portal HTN and Varices
  • Ascites and SBP
  • Hepatorenal syndrome
  • Hepatic encephalopathy
  • Hepatocellular carcinoma
34
Q

What does the malnutrition in cirrhosis lead to?

A

Muscle wasting

35
Q

Why does muscle wasting occur in malnutrition?

A

1- Liver cannot store glucose as effectively

2- Muscle tissue used as a fuel

36
Q

How is malnutrition managed?

A
  • Regular meals (e.g. 3 hourly)
  • Low sodium, high protein diet
  • No alcohol
37
Q

Which two veins make the portal vein?

A

SMV and Splenic Vein (IMV joins splenic vein)

38
Q

How do varices occur?

A

The anastomoses of the systemic and portal systems means that the systemic veins become swollen and tortuous.

39
Q

Where do varices occur?

A
  • Gastro-oesophageal junction
  • Ileocaecal junction
  • Rectum
  • Umbilical vein at the anterior abdominal wall
40
Q

What does exsanguinate mean?

A

Bleed out

41
Q

How are stable varices treated?

A
  • Propanolol (reduces portal HTN)

- TIPS, Band Ligation or injection

42
Q

How does band ligation work?

A

Elastic band around the varices, closing them off

43
Q

What does TIPS stand for?

A

Transjugular Intra-hepatic Portosystemic shunt

44
Q

How does TIPS work?

A

1- XR guided wire from Jugular vein, down Vena Cava and into the hepatic vein

2- Hepatic vein then joined to the portal vein, within the liver

3- Pressure relieved

45
Q

How does variceal injection work?

A

Sclerosant injected, shrinking the varices

46
Q

How are bleeding varices treated?

A
  • Resuscitation
  • Urgent endoscopy
  • Sengstaken-Blakemore Tube
47
Q

How are bleeding varices resuscitated?

A
  • Vasopressin analogue (terlipressin)
  • ABx (broad spectrum such as Co-amox)
  • Correct coagulopathy (VitK, FFP)
  • Consider ITU
48
Q

What is FFP?

A

Bags of clotting factors

49
Q

What can endoscopy allow?

A
  • Injection of sclerosant (inflammatory obliteration)

- Band ligation

50
Q

What is a Sengstaken-Blakemore Tube?

A

Tube inserted to tamponade the bleeding varices

51
Q

When is Sengstaken-Blakemore used?

A

When endoscopy fails

52
Q

How does Ascites occur?

A

1- Portal HTN pushes fluid out of capillaries in the liver and bowel, into the peritoneal cavity

2- BP drops

3- RAAS Activation causes fluid retention and sodium overload

53
Q

What kind of ascites does cirrhosis cause?

A

Transudative (low protein)

54
Q

How is ascites managed?

A
  • Ascitic tap (paracentesis)
  • Low-sodium diet
  • Spironolactone
  • Ciprofloxacin prophylaxis (SBP)
  • Consider TIPS/Transplant
55
Q

What is SBP?

A

Infection in the ascitic fluid

56
Q

What are the most common organisms in SBP?

A
  • Escherichia coli
  • Klebsiella pneumoniae
  • Gram positive cocci (Staph and enterococcus)
57
Q

How does SBP present?

A

Can be asymptomatic or:

  • Fever
  • Abdo Pain
  • Deranged bloods
  • Ileus
  • Hypotension
58
Q

How is SBP managed?

A
  • Ascitic culture

- IV Cephalosporin (cefotaxime)

59
Q

What is hepatorenal syndrome?

A

1- Portal veins dilate

2- Blood volume lost elsewhere e.g. kidneys

3- RAAS Activation (renal vasoconstriction)

4- Starvation of the blood to the kidney and rapid deterioration in kidney function

60
Q

What’s the prognosis in hepatorenal syndrome?

A

1 week unless liver is transplanted

61
Q

What is hepatic encephalopathy?

A

Build-up of toxins affecting the brain

62
Q

Which toxin is important in hepatic encephalopathy?

A

Ammonia

63
Q

How is ammonia produced?

A

Intestinal bacteria when they break down proteins

Absorbed into the gut

64
Q

Why does ammonia build-up in the blood? (2)

A

1- Liver cannot metabolise it to harmless waste products

2- Collateral vessels between portal and systemic circulation lets ammonia bypass the liver

65
Q

What may predispose to hepatic encephalopathy?

A
  • Constipation
  • Electrolyte disturbances
  • Infection
  • Sedative medications
66
Q

How is hepatic encephalopathy treated?

A
  • Lactulose for 2-3 loose stools a day
  • ABx (Rifaximin)
  • Nutritional support e.g. NG
67
Q

How does the lactulose cure hepatic encephalopathy?

A

Clears the ammonia before it is absorbed

Junior Medicine- GI (18 decks)

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