Cirrhosis, portal hypertension & Varices Flashcards
What are the consequences of Liver cirrhosis on the body?
- Liver failure
- Portal hypertension - due to increased difficulty of getting blood through a fibrosed liver
- Oesophageal varices - from increased portal vein pressure
- Low platelet count - due to increased vein pressure to the spleen
- macroshunting - varices formed around the liver via the vena cava
- Hepatocellular carcinoma
What causes Cirrhosis?
Common:
- Alcohol
- Hep B + Hep D
- Hep C
Other:
- PBC + PSC
- autoimmune hepatitis
- metabollic (Fe, Cu2+, anti trypsin)
- CF
- Drugs - amiodarone, methyldopa, methotrexate
- Idiopathic
Define Cirrhosis.
An advanced stage of live fibrosis characterised by:
- disfigured hepatic architecture due to fibrosis leading to decrease in diffusion of hepatocyte
- development of venous arterial shunts within the liver
What’s the pathophysiology of cirrhosis?
- Chronic injury to to the hepatocytes
- Fibrosis & scarring
- CIRRHOSIS
How do you monitor a patient with cirrohsis?
- regular liver tests for decompensation (LFTS) + alpha fetoprotein (for HCC)
- 6 monthly USS w/ MRI/CT to confirm for HCC monitoring
- 2-3 year gastroscopy for variceal monitoring
- ? transplant
Why does portal hypertension happen?
- Increased venous pressure in the liver due to increased difficulty getting blood through the liver because of fibrosis
- leads to an increased venous pressure backed up in the portal vein which effects surrounding organs that drain into the portal vein (stomach, spleen, IVC shunting)
What are the Sx of portal HTN?
- upper GI bleed
- Ascites
- Encephalopathy
- low platelet count
What may Liver bloods show for Cirrhosis/portal HTN?
Early stages:
- AST/ALT - normal or slightly raised (leakage from damaged hepatocytes)
- ALP - increased depending on cuase
- GGT - Large increase in alcoholics
- Anaemia - microcytic, normocytic, macrocytic depending on cause
- thrombocytopenia - splenomegaly
- AST/ALT ratio high in alcohol (toAST with ALCOHOL)
- AST/ALT ratio low in NASH
Advanced:
- Albumin - decreased due to decrease liver productivity
- Prothrombin time - decreased - decreased hepatic production of coagulation V/VII
- IgG increased -
What imaging would you do for cirrhosis?
- USS - small or large liver, splenomegaly, focal lesions, reversed flow in portal vein
- MRI - MELD scoring
Any other tests for cirrhosis you wanna do?
- ascitic tap - MC&S
- Liver biopsy to confirm diagnosis
How do you manage Cirrhosis?
- IRREVERSIBLE
- manage complications:
- propanolol for portal HTN
- livery vaccines
- colestyramine - helps with puritis
- MELD <18 eligible for transplant - only curative option
- diuretics (spiro or furose)
- therapeutic paracentesis
- TIPS (if indicated)
- maybe prophylactic Abx for ascites (ceftriaxone)
- dietitian input for protien & salt advice
-Manage cause e.g. alcohol misuse, hep B, etc
Other than Cirrhosis what other causes of Portal HTN are there?
- prehepatic = portal/splencic vein thrombosis
- intrahepatic - mostly cirrhosis (UK), Schistosomiasis (rest of the word), sarcoid
- posthepatic - blockage from outside liver - budd-chairi, RHF, Pericarditis, veno-occlusive disease
Why does hepatic encephalopathy become a thing?
- Toxic substates accumulate in the blood (urea, amonia, NO) that would usually be excreted by the liver
- Cross BBB
- metabolised in the brain = glutamine increase
- causes swelling & therefore brain dysfunction
What are the 4 stages of hepatic encephalopathy?
- I = inverted sleep cycle
- II = lethary + personality changes
- III = worsened confusion
- IV = COMA
what’s the acute treatment for bleeding oesophageal varicies?
- Fluid resus
- ocreotide 3-5/7
- prophylactic abx ceftriaxone Iv 7/7
- endoscopic bind ligation
