Cirrhosis - Clinical Flashcards
pathophysiology of cirrhosis
fibrosis
haemodynamic
what does the hepatic portal vein carry
newly absorbed nutrients, drugs and microbes and toxins from GI tract to the liver
pressure of the hepatic portal vein
very loss pressure - with only a small gradient across the liver to hepatic vein
collateral pathways of portal systemic venous system
oesophageal and gastric venous plexus
umbilical vein from left portal vein to epigastric venous system
retropeortineal collateral vessels
hemorrhoidal venous plexuses
causes of portal hypertension
cirrhosis
prehepatic
intraheptic
describe prehepatic portal hypertension
blockage of the portal vein before the liver
causes of prehepatic portal hypertension
portal vein thrombosis or occlusion secondary to congenital portal venous abnormalities
describe intrahepatic portal hypertension
due to distortion of liver architecture
causes of intrahepatic portal hypertension
presinusoidal - schistosomiasis, or Non-cirrhotic Portal Hypertension
postsinusoidal - cirrhosis
Budd Chiari syndrome and veno-occlusive disease
causes of post sinusoidal intrahepatic portal hypertension
cirrhosis
alcoholic hepatitis
congenital hepatic fibrosis
aetiology of cirrhosis
alcohol
HVC
NASH (NAFLD)
epidemiology of cirrhosis
adults - 25-65
clinical presentation of compensated cirrhosis
clinical findings normal - incidental finding
portal hypertension
abnormalities in imaging and lab tests
clinical presentation of decompensated cirrhosis
liver failure - acute or chronic
end stage liver disease - insufficient hepatocytes
signs of compensated cirrhosis
Spider naevi Plamar erythema clubbing gynaecomastia Hepatomegaly(?) Spleenomegaly or none
signs of decompensated cirrhosis
Jaundice
Ascites
Encephalopathy
bruising
complications of cirrhosis
ascites encephalopathy varcieal bleeding liver failure hepatocellular carcinoma
treatment for decompensated cirrhosis
remove or treat underlying cause
avoid NaCl retention
increased nutritional intake (protein, vitamin B and calories)
why does liver require extra nutritional needs
liver switches to gluconeogenesis and lipolysis - increasing weight loss
test for ascites
ultrasound - shifting dullness and darkness
treatment for ascites
improve underlying liver disease and infection
reduced salt intake, maintain nutrition
diuretics - spironolactone
paracentesis
trans-jugular intra-hepatic porto-systemic shunt (TIPSS)
transplantation
NO NSAIDS
describe paracentesis
rapid relief
risk of infeciton
encephalopathy
hypovolaemia
outcomes of TIPSS
60% - no more ascites
30% - ascites controlled with diuretics
10% - no improvement
what is spontaneous bacterial peritonitis (SBP)
translocated bacterial infection of ascites
diagnosing SBP
tap in all ascites and cell count - neutrophil count > 250 cells
treatment for SBP
urgent! Antibiotics and Alba Vascular instability-terlipressin Maintain renal perfusion HRS development very poor prognosis
pathology of encephalopathy
microglial inflammation
ammonia glutamate/glutamine shuttle
diagnosing encephalopathy
flap confusion
any neurology
alcohol withdrawal
describe how hepatic encephalopathy is caused
ammonia generated in intestines from nitrogenous compounds is taken directly into system circulation than being metabolised in liver
causing disturbances in neurotransmitter trafficking
encephalopathy treatment
treat underlying infection., metabolic, drugs or liver failure
rifaxamin - clear gut
maintain nutrition
transplant
treatment for primary prophylaxis
beta-blockers - propranolol, carvideolol
variceal ligation
treatment for acute variceal bleeding
resuscitation
terlipressin
endoscopy - banding
TIPSS (failure in therapy)
treatment for secondary prophylaxis
variceal band ligation
beta-blockers
how is waiting list mortality based for liver transplantation
UKELD score > 49 to be listed for elective liver transplant
unless diagnosed with variant syndrome or hepatocellular carcinoma
