Cirrhosis, CLD complication, fatty liver disease Flashcards
List causes of cirrhosis
- Alcoholic liver disease
- Nonalcoholic fatty liver disease (fatty liver)
- Hepatitis B
- Hepatitis C
- Drugs
- Ethanol **
- Fatty liver
- Genetic: copper, alpha-1 antitrypsin deficiency
- Haemochromatosis
- Immune: AIH (Autoimmune Hepatitis), PBC (Primary Biliary Cholangitis), PSC (Primary Sclerosing Cholangitis)
DESCRIBE CLiiical featurs of cirrhosis
- spider naevi
- palmar erythema
- ascites
- white nails/leuconychia
Hepatic damage–>insufficiency:
- coma
- jaundice
- liver damage
- anaemia
- haemorrhage
- oedema
- ascites –also portal hypertension
- note hepatic damage also results in hyperestrinism, causing spider naevi, gynaecomastia, pectoral alopecia, altered hair distribution, palmar erythema and testicular atrophy
- portal hypertension
- oeso varices
- splenomegaly
- caput medusae
- ascites
- ankle oedema
- hyperspenism–> bone marrow changes
Routes to mortality from liver disease
- Bleed (varices)
- Infection (spontaneous bacterial peritonitis)
- Cancer (HCC - Hepatocellular Carcinoma)
- Coma (encephalopathy)
- Renal failure
Describe ascites, relationship to liver disease, and how to determine if ascites, infection, neoplastic process involved
- 85% (cirrhotic)
-
15% (non-cirrhotic)
- Renal
- Cardiac
- Peritoneal metastasis
Ascites: Questions to Ponder
- Is it cirrhotic ascites?
- SAAG (Serum albumin - ascites albumin gradient) > 11 g/L indicates portal hypertension
- Is there infection?
- Neutrophils > 250/cu.mm
- Is there cancer?
- Cytology
Describe pathophysiology of ascites
see also [[Gastroenterology - Lecture 5]]
- renal retention of sodium
- reduced effective arterial blood volume (due to stiffliver)
- activates RAAS, SNS, ADH
- Na, H2O retention and increased plasmavolume
- compartmentalisation of fluid to peritoneal cavity
- increased hydrostatic pressure due to stiff liver, lymphatic flow
—-> ascites
Describe management of ascites
- Salt restriction (2 g/day)
-
Diuretics:
- Start with spironolactone - due to high aldo conc
- Add frusemide
- Monitor weight, U&E, urine sodium to prevent complications from diurtic use
- No need to restrict fluid (unless Na+ below 120)
describe treatment of diuretic-resistant ascites
- Definition: Ascites not responding to max doses or adverse effects develop/not tolerated
-
Large volume paracentesis with albumin (supplement Albumin 8-10 g/litre fluid removed)
- To prevent postparacentesis circulatory dysfunction
Describe sbp
- Signs: Often none, nonspecific; diagnosis by ascitic fluid test - WCC >250–> antibiotics
- Treatment: IV antibiotics (e.g., ceftriaxone) for 5 days
- Prevention: Prophylactic oral antibiotics if there is a history of SBP; in patients with GI bleed
Descrieb hepatic encephalopathy
- Impaired neuropsychiatric syndrome due to acute or chronic liver disease
- Hepatic encephalopathy in essence: ammonia intoxication as a result of portal shunting to brain, altering mental state
- ammonia end-product of protein metabolism in intestine, due to bacteria
- shunted to liver, normal de-toxxed to urea and excreted
-
Grades I (mild confusion, non-specific, poor sleep, ‘night watchman- awake at night, asleep in day’) to IV (coma)
- FLAP/Asterixis - more prominent in GII/III - unlikely in GI
- neuropsychiatric symptoms worsens in III
-
STROOP TEST/psychometric number connection tests (timed test)
- can be used to check response to treatment
-
Remember!
- There are other causes of confusion: SDH, sedating drugs and meds, hyponatremia, hypoglycaemia, withdrawal delirium from alcohol or Wernicke’s
Describe hepatic encephalopathy management
- Treat precipitating factors (infection, drugs, constipation, hypokalaemia, GI bleeding) -> helps improve encephalopathy
-
Lactulose (MAIN STAY)
- How does it work?
- Acidifies gut (reduces ammonia)
- Inhibits ammonia-forming bacteria
- Acts as a laxative
- How does it work?
-
Antibiotics: Sterilize gut - if not responsive to lactulose
- Rifaximin
- Metronidazole
- Neomycin (historical)
- combination of lactulose and antibiotics may be useful, eg if lactulose poorly tolerated ie patient becomes bloating
What are other consequences of cirrhosis?
- Kidneys: Hepatorenal syndrome (decreased blood flow)
- Lungs: Hepatopulmonary syndrome (rare), portopulmonary hypertension
-
Grading of cirrhosis severity
- CHILD-PUGH score, MELD score -
Describe varices and their significance
- back flow of blood into portal vein tributaries
- eg stiff liver —> left gastric and oesophageals anastomoses at GEJ; rectal anastomoses and haemorrhoids
Varices - Why Are They Important?
- Most (80%) cirrhotics will develop varices.
- Main cause of upper GI bleeding in cirrhosis (peptic ulcer, other causes less often).
- High mortality from bleed and rebleed (SCREEN ALL CIRRHOTICS).
- use platelet count, liver stiffness measurements i.e. fibroscan to screen
Describe management of varices
- Prevent: Prevent bleeding through banding or drugs that lower portal pressure (propranolol, carvedilol - beta blocker with alpha blocking action, may be useful in liver specifically). ^[avoid non-selective drugs in asthmatics]
- Bleeding: Treat bleeding with banding + drugs that lower portal pressure (octreotide IV/infusion - somatostatin analog).
- Prevent Re-Bleeding: Prevent re-bleeding through banding.
Descrieb managing acute bleeding from varices
- Bleeding can be SEVERE.
- Protect airway e.g. intubation, aim for Hb 80 g/L.
- Administer antibiotics and lactulose.
- SBP (Spontaneous Bacterial Peritonitis) and encephalopathy are common after a bleed.
- Antibiotics also reduce rebleeding risk.
- Start octreotide (reduces splanchnic flow).
- Endoscopy
##### Endoscopic Variceal Ligation (EVL) - EVL is 90% effective for control of acute bleeding.- done monthly until all variceal columns targeted
List alternatives to endoscopy
- If endoscopy fails:
- Balloon Tamponade: Sengstaken-Blakemore tube – OCCLUDE varices.
- Transjugular Intrahepatic Portosystemic Shunt (TIPS): DIVERT BLOOD.
- Surgery: Very rare now.
Sengstaken-Blakemore Tube (Balloon Tamponade)
- compress haemorrhaging vessels to occlude
#### Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- DIVERT BLOOD.
