Cirrhosis, portal hypertension + varices

Question 1

Cirrhosis

Answer 1

irreversible liver damage

loss of normal hepatic architecture with bridging fibrosis and nodular regeneration

Question 2

Most common causes of cirrhosis

Answer 2

chronic alcohol abuse

HBV or HCV infection

Question 3

Rarer causes of cirrhosis

Answer 3

Genetic/metabolic: haemochromatosis, a1-ATD, wilsons

Hepatic vein events (Budd-Chiara)

NASH

Autoimmune: PBC, PSC, AIH

Question 4

Chronic liver disease presentation

Answer 4

Leuconychia (white nails/milk spots from low albumin)

Clubbing

Palmar erythema

Spider navei

Parotid enlargement

Hepatomegaly

Question 5

Complications of cirrhosis

Answer 5

1. hepatic failure
2. portal hypertension
3. varices

Question 6

LFT cirrhosis

Answer 6

initially: raised bilirubin, AST, ALT, alkaline phosphate and yGT
later: low albumin, WCC and platelets, raised INR

Question 7

What may liver US + duplex show in cirrhosis?

Answer 7

hepatosplenomegaly
focal liver lesions
hepatic vein thrombus
reversed portal vein flow

Question 8

MRI cirrhosis

Answer 8

caudate lobe enlargement

smaller islands of regenerating nodules

Question 9

Apart from imaging and bloods, what other Ix for cirrhosis?

Answer 9

Ascitic tap: fluid sent for urgent MC&S
Liver biopsy (confirms Dx)

Question 10

General Tx cirrhosis

Answer 10

good nutrition
stop alcohol
avoid NSAIDs, sedatives + opiates
Colestryramine for itching

Question 11

What should be considered in any cirrhosis pt who deteriorate rapidly?

Answer 11

SBP

common organisms: E.coli, klebsiella and strep

Question 12

how can renal failure develop as a result of cirrhosis?

Answer 12

decreased clearance of immune complexes –> they get trapped in the kidney

Question 13

whats the only definitive Tx for cirrhosis?

Answer 13

transplant!

Question 14

what forms the portal vein?

Answer 14

superior mesenteric (from the gut) and the splenic vein (from the spleen)

Question 15

what account s for 25% of hepatic vascular inflow?

Answer 15

the hepatic artery

the portal vein is 75%

Question 16

what happens if the inflow of normal portal blood to the liver is obstructed?

Answer 16

high pressure proximal to the obstruction

diversion of blood into portosystemic collaterals

e.g. at the gastro-oesophageal junction (varices), where they are superficial and liable to rupture –> massive GI haemorrhage

Question 17

Main sites of portal blood obstruction

Answer 17

pre hepatic: due to blockage of the portal vein before the liver

intrahepatic: resulting from distortion of the liver architecture
posthepatic: due to venous blockage outside the liver

Question 18

Clinical features portal hypertension

Answer 18

GI bleeding from oesophageal or less commonly gastric varices

ascites

hepatic encephalopathy

Question 19

what are ascites?

Answer 19

accumulation of fluid in the peritoneal cavity, causing abdominal swelling