Cirrhosis -Jenkins Flashcards
What is cirrhosis? What does this lead to?
- histologically=diffuse fibrosis and the conversion of normal liver architecture into structurally abnormal nodules
- fibrosis: activation of hepatic stellate cells–> formation of inc amounts ofcollagenand other components of the extracellular matrix
–> dec in hepatocellular mass and function and alteration in blood flow
What does cirrhosis of the liver look like on ultrasound?
-ascities with a small nodular liver
Can cirrhosis be reversible?
In early stages, especially if it is due to HCV, it can be responsive to treatment
advanced stages =liver transplant
***What is the most common cause of cirrhosis in the United States?
Fatty liver d/t: #1 Hep C, #2 Alcoholic liver disease
What labs can be used for prognosis of end stage liver disease?
- cholesterol ( inc INR)
- albumin (low is poor prognosis because made in liver)
***What can the AST and ALT be in cirrhosis? What do these labs indicate?
in cirrhosis, can be normal
indicate inflammation
highest AST and ALT in alcoholic hepatitis or NASH
What will cause a super elevated ALP?
biliary disease
What will bilirubin levels be in cirrhosis?
normal in well-compensated cirrhosis but will rise as cirrhosis progresses
***TRUE OR FALSE: Hepatitis B is the most common case of cirrhosis
FALSE (Hep C is, along with alcohol and fatty liver)
What are some complications of cirrhosis?
- portal HTN –> hemorrhoids, esophageal varices, ascites, hypersplenism
- ascites: excess fluid (lymph) in the peritoneal cavity
- hepatorenal syndrome (renal vasoconstriction)
- hepatopulmonary syndrome
- hepatic encephalopathy
- hyponatremia
- malnutrition
- osteoporosis
- hypogonadism
- fetor hepaticus (sweet, pungent breath)
- Dupuytren’s contracture
What are the most common treatments for acute variceal bleeds? What procedure can be done to prevent re-bleeds?
band ligation and octreotide (a splanchnic vasoconstrictor)
TIPS to prevent re-bleeds if other tx fails
What is an important complication of TIPS?
a stent is placed to release portal HTN into the vena cava==> bypass the liver
–> risk of toxins (ammonia) is higher –> greater risk of hepatic encephalopathy
***What is the pathophysiology of ascites due to cirrhosis?
-vasodilation of the splanchnic system leads to dec filling in systemic system–> inc RAAS –> inc Na+ and H2O retention)
-hypoalbuminemia also causes a dec plasma oncotic P –> more leaking fluid into the peritoneal cavity –> more peripheral edema
(*Sum: increased portal pressure and low albumin)
What other complications can result from ascites?
- resp function can be compromised –> SOB
- malnourished
- mm wasting
- anorexia
- fatigue
- abd discomfort and pressure
- gynecomastia
- Spontaneous bacterial peritonitis
- hydrothorax (pleural effusion)
How can you determine if someone has ascites or is just fat?
- shifting dullness in percussion when pt is supine vs on side
- fluid wave (non-specific)
- US (can detect as little as 30 mL of fluid)
What is the treatment for severe ascites?
Paracentesis : needle into the peritoneal cavity to drain the ascitic fluid (also used for dx)
also, *diuretics (spironolactone) and sodium restriction
-should also be done when present with ascites for the 1st time to diagnose the fluid
***What is the #2 cause of ascites?
cancer (ovary and liver)
cirrhosis is #1
What are the most typical symptoms of spontaneous bacterial peritonitis? What should be the suspected cause if 2+ organisms are found in the ascitic fluid?
fever and abd pain
2+ organisms==> suspect a perforated viscus
What is the 1 year survival rate of someone with massive ascites?
< 50%
liver transplant needed
How does INR correspond to prognosis of cirrhosis? Why?
higher INR==> worse prognosis
clotting factors are created by the liver.
Vitamin K requires biliary excretion for its absorption. liver failure–> Less vitamin K –> dec 2, 7, 9, and 10 clotting factors
What can hypersplenism lead to? What physical finding can be seen?
thrombocytopenia (sequestration of platelets–> low platelets)
petichiae
can also lead to DIC
***What is pancytopenia? What is the most common cause of this?
pancytopenia=thrombocytopenia (low platelets), leukopenia (low WBC) and anemia (low hemoglobin)
cirrhosis (hypersplenism)
What is the #1 cause of anemia in cirrhosis?
hypersplenism
What is the reason hyponatremia is common in pts with cirrhosis and ascites?
inability to excrete free water because of high levels of ADH (activated by systemic vasodilation)
–> low sodium
What is the best therapy for hepatorenal syndrome?
liver transplant
What is hepatopulmonary syndrome? Is this the same as hepatic hydrothorax?
Triad of:
- Liver disease
- Increased alveolar-arterial gradient while breathing room air
- Evidence of intrapulmonary vascular dilatations
NOT THE SAME!
***What are the 2 main causes of death due to cirrhosis?
hepatic encephalopathy and GI bleeding
***What is asterixis? Which pts will present with this?
bilateral but asynchronous flapping motions of outstretched dorsiflexed hands
seen in pts with hepatic encephalopathy
What medications are used to treat hepatic encephalopathy? (3)
- LACTULOSE (first line) (stimulates ammonia passage from tissues to gut lumen and inhibits ammonia production)
- Neomycin (antibiotic)
- other antibiotics
(3 meds==> ALL oral. if pt is comatose–> NG tube)
What is the difference between compensated and decompensated cirrhosis? What is the median survival with both?
(Important for transplants)
- compensated=no major complications
- -> median survival is 12 years
- decompensated=have complications (i.e. variceal bleeding, SBP, hepatocellular carcinoma, etc)
- -> median survival is < 6 months
What is Dupuytren’s contracture? What type of cirrhosis is this commonly seen in?
- results from thickening and shortening of the palmar fascia –> flexion deformities of the fingers
- common in alcoholic cirrhosis
What are some other PE findings in cirrhosis?
- Jaundice
- scleral icterus
- palmar erythema
- Muehrcke’s nails (transverse white bands in the nails that do not indent)
- Terry’s nails (proximal 2/3 of the nail bed is white and distal 1/3 is red)
- clubbing
- spider angiomata (spider telangiectasis)
***What is the treatment for cirrhosis?
- Intravascular volume is low so aldosterone level would be very high → retain sodium and water:
1. Fluid restriction (makes aldosterone higher though)
2. Na restriction (lowers intravascular volume → raises aldosterone)
3. Lasix (lowers intravascular volume → raises aldosterone)
4. Spironolactone (given to every patient b/c anti-aldosterone) - TIPS – decreases ascites and varices
- La Veen shunt
- Liver transplant – ultimate treatment
