Cirrhosis + Liver Tumors B&B

Question 1

how does cirrhosis affect the gross appearance of the liver?

Answer 1

liver tissue replaced by fibrosis and nodules —> bumpy, shrunken liver

Question 2

what are the symptoms of hyperammonemia caused by cirrhosis?

Answer 2

asterixis (hand flapping), confusion, coma

Question 3

what is the treatment for hyperammonemia caused by cirrhosis? (2)

Answer 3

1. low protein diet
2. lactulose: laxative (synthetic disaccharide), broken down to fatty acids in colon —> lowers pH, favoring formation of NH4+ (over NH3) which cannot be absorbed

Question 4

what hormonal abnormality is caused by cirrhosis? how does this present? (3)

Answer 4

elevated estrogen - liver normally removes estrogen

1. gynecomastia in men
2. spider angiomata (skin)
3. palmar erythema

[just remember that estrogen can make your skin red]

Question 5

explain the hemodynamic changes (2) that occur in cirrhosis that cause an increase in total body water (and edema, ascites, etc)

Answer 5

1. loss of albumin —> decreased oncotic pressure causes a decrease in effective circulating volume, so RAAS/ADH are increased in response
2. increased NO release —> vasodilation causes a decrease in SVR and BP, so SNS is activated to raise CO and RAAS/ADH

Question 6

name 4 key locations were collaterals between the portal and systemic veins can become engorged and symptomatic in patients with portal HTN

Answer 6

collaterals between systemic and portal veins are normally small/collapsed because pressure is equal between systems… in portal HTN, pressure causes collaterals to open/engorge

1. umbilicus —> “caput medusa”
2. esophagus —> upper GI bleeding
3. stomach —> upper GI bleeding
4. rectum —> hemorrhoids

Question 7

what is the mechanism of low platelets in patients with cirrhosis?

Answer 7

splenic vein drains into portal system… back pressure from portal HTN causes engorgement of the spleen —> low platelets

Question 8

2 reasons why a patient could develop new or worsening ascites - how can these be differentiated?

Answer 8

portal HTN or malignancy (leaky vasculature)

differentiate via SAAG (Serum Ascites Albumin Gradient): take sample of fluid via paracentesis and subtract level of albumin from serum albumin:

serum albumin - ascites albumin = SAAG

high SAAG (>1.1g/dL) = portal HTN
low SAAG (<1.1g/dL) = malignancy

Question 9

what is the DOC for treating ascites?

Answer 9

spironolactone: K+ sparing diuretic, blocks aldosterone in distal tubules

can add loop diuretics (furosemide) if extra strength is needed, can also take large volume paracentesis, can also do TIPS (surgical, connects portal vein to hepatic vein)

Question 10

which 2 infectious agents most commonly cause spontaneous bacterial peritonitis (SBP)? what is the tx?

Answer 10

SBP = infection of ascites fluid, bacteria gain enters via gut

typically E. coli or Klebsiella (Gram neg.)

tx = cefotaxime (3rd gen. cephalosporin) - provides good gram +/- coverage

Question 11

MELD Score

Answer 11

Model for End-stage Liver Disease: scoring system for chronic liver disease or cirrhosis, estimates 3-month mortality

takes into account bilirubin levels, creatinine, INR - these assess how well the liver is functioning [AST/ALT really only assess inflammation]

Question 12

Child-Pugh classification

Answer 12

predicts risk/survival from cirrhosis based on 5 variables: encephalopathy, ascites, bilirubin, albumin, PT

5-6 = class A cirrhosis
7-9 = class B cirrhosis
10-15 = class C cirrhosis (bad!)

Question 13

which cell type becomes activated in liver disease and is a major contributor to cirrhosis

Answer 13

stellate cells: perisinusoidal, storage site for retinoids (vit A metabolites) and secrete TGF-beta

proliferate and produce fibrous tissue

Question 14

what is the most common primary liver tumor, and how does it typically develop?

Answer 14

hepatocellular carcinoma - usually a consequence of chronic liver disease

ex - hep B/C, alcoholic cirrhosis, Wilson’s Disease, hemochromatosis, alpha-1 antitrypsin

Question 15

which fungus is associated with hepatocellular carcinoma? what are the risk factors?

Answer 15

aspergillus produces aflatoxin, which can contaminate corn, soybeans, peanuts

high rates of dietary intake are a risk factor in non-industrialized countries (no screening for aflatoxin) or those who eat a lot of locally-grown foods

Question 16

a rise in ____ can be suspicious for progression of chronic liver disease to hepatocellular carcinoma

Answer 16

alpha fetoprotein (AFP) - can be elevated in chronic liver disease, but a rise in level from baseline is suspicious for HCC

note HCC can also secrete EPO

Question 17

how does hepatocellular carcinoma (HCC) spread and to where? (2)

Answer 17

via hematogenous (blood) to lung + bone

HCC is poorly responsive to chemo/radiation and has poor prognosis

Question 18

what 2 risk factors are associated with hepatic adenoma? in whom do they most commonly occur?

Answer 18

benign epithelial liver tumors, usually solitary in R lobe, most common in young women (20-40)

associated with oral contraceptives and anabolic steroids

risk of rupture during pregnancy

Question 19

Pt is 34yo F presenting to her GP. She was taking oral contraceptives for 5 years, but stopped 1 year ago to try to conceive with her husband. Labs reveal she is pregnant, and a liver resection is planned. Why?

Answer 19

hepatic adenoma: benign epithelial liver tumors, usually solitary in R lobe, most common in young women (20-40)

associated with oral contraceptives and anabolic steroids

risk of rupture during pregnancy

Question 20

this benign liver tumor is usually not biopsied due to concern of fatal hemorrhage - what is?

Answer 20

hepatic (cavernous) hemangioma: most common benign liver tumor, composed of vascular spaces often filled with thrombus

biopsy is avoided due to risk of massive hemorrhage

Question 21

what is the major concern with hepatic hemangiomas?

Answer 21

hepatic (cavernous) hemangioma: most common benign liver tumor, composed of vascular spaces often filled with thrombus

biopsy is avoided due to risk of massive hemorrhage

Question 22

what are hepatic angiosarcomas associated with? (2)

Answer 22

very rare, high-grade, malignant vascular tumor associated with toxic exposures:

1. vinyl chloride - used to make PVC plastic
2. arsenic - industrial uses

Question 23

from where do metastasis to lung most commonly come? (3)

Answer 23

1. GI (colon, stomach, pancreas)
2. breast
3. lung

metastasis will have multiple nodules, primary will have single nodule