Clin Med- Cirrhosis Flashcards
1
Q
Cirrhosis overview
A
- means condition of yellow/tawny, aka jaundice
- med management has improved pt morbidity but transplant remains only curative treatment
- liver does well until function is <10%
2
Q
Cirrhosis
- race more prevalent
- M vs. F
- what life conditions have higher prevalence
- common cause
A
- higher rate in non-hispanic blacks, mexican americans
- M>F
- below poverty line, less than 12th grade education
- viral hepatitis, DM, ETOH
3
Q
5 most common causes of Cirrhosis
A
- Chronic Hep C (most common in US)
- Alcohol liver disease (2nd most common)
- Nonalcoholic steatohepatitis (becoming more common - obesity)
- chronic Hep B (asians and africans)
- Other: drug induced, genetics
4
Q
Quick overview: how does alcohol lead to cirrhosis
A
- increase in NADH stimulates fat storage in hepatocytes
- acetylaldehyde binds to macromolecules, signals immune system = inflammation
- reactive oxygen species, they are bad
5
Q
How does hepatocyte death cause scarring of the liver?
A
- dead cells signal stellate cells to produce collagen
- Collagen buildup presses against sinusoids
- decreased diameter or sinusoids leads to portal hypertension
6
Q
How does nonalcoholic steatohepatitis lead to cirrhosis
A
- fatty acids + -OH create water and reactive fatty acid
- eventually causes inflammation and death of hepatocyte
7
Q
Cirrhosis risk factors (7)
A
- ETOH
- IVDU (hep C)
- Obesity/NAFLD
- Male
- Low income/poverty
- Low education level
- Hispanic
** >80% chronic liver disease is preventable…
8
Q
What two factors have an additive effect on liver dz?
A
- elevated BMI
- ETOH
9
Q
What is a standard drink volume
A
- 12 oz beer
- 8-9 fluid oz malt liquor
- 5 fl oz wine
- 1.5 fl oz distilled spirit
10
Q
How to define heavy alcohol use
A
Men
- > 4 (2?) drink a day OR
- > 14 drinks per week
Women
- > 3 (1?) drink a day OR
- > 7 drinks per week
Per Nat’l Inst on Alcohol Abuse and Alcoholism
11
Q
Describe the progression of liver damage
A
Health Liver
- Fibrotic liver
- Cirrhotic liver
- Liver cancer
12
Q
Fibrotic liver define
A
- continuous inflammation (hep C) can lead to fibrosis
- formation of scar tissue within the liver
13
Q
Cirrhotic liver define
A
- extensive scarring can block flow of blood through liver
- cause liver function to deteriorate over time
14
Q
Liver cancer define
A
- Hep C is leading cause
- formation of malignant tumor in liver
15
Q
6 Pathophysiologic changes dt cirrhosis
A
- Unable to process bile- jaundice, scleral icterus, pruritus
- Unable to produce enough clotting factors - coagulopathy
- sequestration of platelets by spleen - thrombocytopenia
- Low albumin production - ascites and edema
- Lower ability to metabolize drugs - toxic byproducts, longer half lives
- Scarring - portal HTN
16
Q
How/why does the thrombocytopenia occur in cirrhosis?
A
- portal HTN
- increased pressure in spleen
- spleen signals bone marrow to reduce blood formation
- results in decreased platelet count
17
Q
Why use PT/INR instead of liver enzymes to evaluate liver function in cirrhosis??
A
- if all the hepatocytes are sad and dead, no more enzymes to leak so won’t be elevated
- PT/INR is better indicator
18
Q
When do sx appear in cirrhosis?
A
often non until late stage
19
Q
Cirrhosis sx
A
- fatigue, weakness (anemia)
- anorexia, weight loss
- jaundice, pruritis - hyperbilirubinemia
- absent/irregular menses, chronic an ovulation - elevated estrogen levels
- diminished libido/ED - estrogen in men
- tea urine, clay stool- lack conjugated bilirubin
- edema, bloating - low albumin, kidney damage
- night blindness - fat soluble vitamin malabsorption
- melena/hematemesis if variceal bleeding
20
Q
PE - signs of cirrhosis
A
- skin: spider angiomas, palmar erythema, jaundice, ecchymosis, telangiectasia
- Caput medusa
- nodular liver on palpation
- splenomegaly
- scleral icterus
- ascites / edema
- gynecomastia
- dupuytren contractures
- nails: clubbing, white, horizontal white bands
- Asterixis: hand flapping tremor
- Mental change, fog, confusion
- muscle wasting
- Foetor hepaticas (breath of the dead) which is sweet, pungent dt thiols in lungs
21
Q
Cirrhosis ddx - four
A
- other causes of portal HTN
- metastatic or multifocal cancer in liver/biliary tree
- acute alcoholic hepatitis
- drug toxicity (methotrexate, azithioprine)
22
Q
6 Other possible causes of portal HTN (ddx)
A
- portal vein thrombosis, splenic vein thrombosis
- lymphoma, splenomegaly
- Non-cirrhotic portal fibrosis
- Extra hepatic portal vein obstruction
- Sarcoidosis
- Schistosomiasis
23
Q
Basic lab workup for cirrhosis
- CMP
- albumin
A
- AST and ALT mild elevation
- AST:ALT >1
- alk phos but <3-fold
- elevated GGT (alcoholic)
- later elevation of bilirubin
- low albumin
- hyponatremia
24
Q
what lab test is the best indication for mortality
A
bilirubin
25
Lab WU for cirrhosis
- CBC
- lipid
- bleeding studies
- anemia (hemolysis, folate def., splenomegaly)
- leukopenia
- decreased platelet
- low cholesterol
- prolonged PT/INR, PTT
26
Additional lab tests to perform with Cirrhosis
- screen from HBV and HCV (screening panel with PCR for viral load)
- Antimitochondrial anti for primary biliary cirrhosis
- autoimmune hepatitis
- alpha fetoprotein for HCC
- elevated ammonia if mental changes
- hemochromatosis screening
- Wilson's disease via Ceruloplasmin
- Alpha1-antitrypsin phenotype screen
27
Cirrhosis imaging
| - what is best initial test
Abd US
- can sometimes note nodules
- good initial test for masses, screen q6 months for HCC
28
Cirrhosis imaging
| - what is doppler US best for?
hepatic and portal veins for thrombosis
29
Cirrhosis imaging
| - when use MRI?
- fu eval of masses seen on US
| - if elevated alpha fetoprotein
30
Cirrhosis imaging
| - when use US elastography
- safer than liver biopsy but not widely avail
| - measures stiffness of liver tissue to distinguish level of fibrosis
31
Cirrhosis imaging
| - when use endoscopic testing?
- EGD
- r/o esophageal varicies
- r/o portal HTN gastropathy
32
What is the gold standard for definitive dx of cirrhosis?
Liver biopsy
33
Liver biopsy for cirrhosis
- should be done as initial workup in compensated pt
- if INR <1.5 and platelets >70,000
- grade inflammation and fibrosis staging
- unnecessary if clear signs decompensation are noted (ascites, varies)
34
Histology of liver biopsy classic findings
- regenerative nodules
| - fibrous tissue bridge portal tracts
35
Histology of liver biopsy in alcoholic liver dz
- steatosis
- polymorphonuclear leukocyte infiltrate
- ballooning of hepatocytes
- Mallory bodies
- giant mitochondria
36
Histology of liver biopsy in chronic hep B & C
periportal lymphocytic inflammation
37
Histology of liver biopsy in NASH
- steatosis
- polymorphonuclear leukocyte infiltrate
- Mallory bodies
- ballooning
(same as alcoholic but lack of giant mitochondria)
38
Histology of liver biopsy in primary biliary cirrhosis
- polymorphonuclear leukocyte infiltrate
- portal inflammation
- loss of bile ducts in portal spaces
39
Histology of liver biopsy in hemochromatosis
- intrahepatic iron stores increased
| - hemosiderosis
40
Histology of liver biopsy in alpha1-antitrypsin deficiency
- periodic acid-shift bodies in hepatocytes
41
Histology
There are a series of slides to review :)
42
Tx of compensated cirrhosis
- No ETOH, drugs, hepatotoxic drugs
| - Antivirals, other meds for hepatitis
43
Tx of compensated cirrhosis due to NASH
- weight loss
- exercise
- control lipids/glucose
44
Tx of compensated cirrhosis due to autoimmune
prednisone
imuran
6-MP
45
Tx of compensated cirrhosis due to hemochromatosis
phlebotomy
46
Tx of compensated cirrhosis due to primary biliary cirrhosis
ursodiol
47
Tx of compensated cirrhosis due to Wilson's disease
penicillamine
48
Decomensated cirrhosis complications
- Varices
- Variceal bleeding
- Ascites
- hepatorenal syndrome
- encephalopathy
- spontaneous bacterial peritonitis
- coagulopathy
* uncompensated - treat complications
49
How to treat varices
- non-selective BB
| - preventative band ligation
50
how to treat variceal bleeding
- band ligation, sclerotherapy
| - shunting
51
How to treat ascites
- diuretics
- low Na diet
- paracentesis
52
How to treat hepatorenal syndrome
- avoid hypovolemia, stop diuretics
- rehydrate
- albumin infusion
53
How to treat encephalopathy
- lactulose syrup
- rifaximin
- metronidazole
54
How to treat spontaneous bacterial peritonitis
- paracentisis
| - abx
55
How to treat coagulopathy
- platelet transfusion
| - blood transfusion
56
How to screen for hepatocellular carcinoma
* cirrhosis is the major risk factor
- US, CT, MRI q 6months
- alpha fetoprotein (poor sen and spec but still used)
- liver transplant
57
When screen for esophageal varices
at time of cirrhosis dx
- EGD +/- banding
- repeat as needed q 1-3 years
58
When paracentesis for ascities
- usually therapeutic, can be dx as well
- d/t discomfort, SOB, risk spontaneous bacterial peritonitis
- PRN q 2-4 weeks
- caution if pedal edema present (not sure why)
59
When to eval for liver transplant
- onset of decompensation (ascites, variceal bleed, encephalopathy)
- jaundice, liver lesion
- MELD or Child-Pugh Score
60
Stable cirrhosis - monitoring
- liver enzymes, platelets, PT q 3-6 months
- HCC screening via abd US q 6 months
- endoscopy at dx and q 1-3 years
61
Cirrhosis diet mods
- NO ETOH
- 4-6 small meals
- low Na
- high fiber
- vitamins and iron
62
Percentage of compensation, decompensation HCC
review slide (at end)
