Cirrhosis, portal hypertension, GE varices

Question 1

What is cirrhosis?

Answer 1

Usually irreversible scarring of the liver due to excessive regeneration after injury, usually due to alcohol or viral infection.

Question 2

What is the pathophysiology of cirrhosis?

Answer 2

When there is injury to the liver (alcohol/HBV/HCV), stellate cells which are normally quiescent start proliferating and secreting TBG-beta-1, which causes collagen production.

Question 3

Describe 3 complications of decreased liver function.

Answer 3

Decreased detoxification, so toxins eg ammonia may get into the brain, causing tremor and coma.
Decreased albumin production - hypoalbuminaemia
Decreased clotting factor production - easy bruising
Decreased estrogen metabolism - gynecomastia, palmar erythema.
Decreased bilirubin coagulation - jaundice.

Question 4

How does cirrhosis cause portal hypertension?

Answer 4

Portal hypertension occurs in cirrhosis due to compression of the central veins and sinusoids.

Question 5

Give 3 complications of portal hypertension.

Answer 5

1. Ascites
2. Congestive splenomegaly
3. Portosystemic shunt including oesophageal varices

Question 6

Give 3 symptoms of cirrhosis.

Answer 6

Tremor (due to toxins in brain)
Easy bruising (decreased clotting factor production)
Pruritis (decreased coagulation of bilirubin)

Question 7

Give 3 signs of cirrhosis.

Answer 7

Leuconychia (white nails due to hypoalbuminaemia)
Clubbing
Spider naevi due to decreased estrogen metabolism.

Question 8

How is cirrhosis diagnosed?

Answer 8

Biopsy: regenerative nodules, bridging fibrosis.
Bloods: thrombocytopaenia; LFTs: AST>ALT, raised ALP and GGT.

Question 9

Describe the management of cirrhosis.

Answer 9

1. Treat the cause, cirrhosis is usually irreversible. Eg, stop alcohol, treat viral infection.
2. Treat symptoms, eg spironolactone for ascites.
3. Liver transplant may be necessary.

Question 10

How is the severity of cirrhosis staged?

Answer 10

Child-pugh classification for cirrhosis: Pour Another Beer At Eleven
Prothrombine time (increases with severity)
Ascites
Bilirubin (increases with severity)
Albumin (decreases with severity)
Encephalopathy.
Each category scores up to 3 so total out of 15.

Question 11

The risk of what cancer is increased with cirrhosis and how is is monitored?

Answer 11

Hepatocellular carcinoma

Alpha-fetoprotein measured every 6 months to screen.

Question 12

What investigations would you do to determine the cause of cirrhosis?

Answer 12

Hepatitis serology - hep B/C?
A1AT - deficiency?
Alpha-fetoprotein -HCC.
Autoantibodies - ANA, AMA, SMA

Question 13

Give a pre-hepatic cause of portal hypertension.

Answer 13

Thrombosis (portal or splenic vein).

Question 14

What is the main hepatic cause of portal htn in the UK?

Answer 14

Cirrhosis (hepatomegaly)

Question 15

What is the main hepatic cause of portal htn worldwide?

Answer 15

Schistosomiasis. (hepatomegaly)

Question 16

Give 2 post-hepatic causes of portal hypertension.

Answer 16

Budd-chiari syndrome (obstruction)
Right heart failure
Constrictive pericarditis
Veno-occlusive disease.

Question 17

What is Budd-Chiari syndrome?

Answer 17

Hepatic vein obstruction by thrombosis or tumour causes congestive ischaemia and hepatocyte damage. Abdo pain, heptomegaly, ascites and high ALT occur.

Question 18

What are varices?

Answer 18

Abnormally dilated vessels, usually occuring in the venous system.

Question 19

What are gastro-eosophageal varices and how are they caused?

Answer 19

Submucosal venous dilatation at the junction between the portal and systemic venous systems. Caused by portal hypertension and can tear, causing variceal haemorrhage.

Question 20

Why might GE varices bleed heavily?

Answer 20

They are likely to be due to or associated with reduced liver function and therefore reduced synthesis of clotting factors.

Question 21

Give 3 clinical features of gastro-oesophageal varices.

Answer 21

Haematemesis, pallor, shock.

Question 22

How are GE varices diagnosed?

Answer 22

Endoscopy, usually indicated by upper GI bleeding, which can be caused by GE varices.

Question 23

Describe the management of GE varices.

Answer 23

1. ABC resuscitation, treat shock
2. Endoscopic banding (oesophageal)/sclerotherapy (gastric)
3. Prophylaxis: beta blocker eg propanolol; endoscopic band ligation, antibiotics.

Question 24

What is the prognosis like for GE variceal bleeds?

Answer 24

70% risk of rebleeding, significant risk of death.