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GI 2 > Clin Med- Cirrhosis > Flashcards

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%
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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
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3
Q

5 most common causes of Cirrhosis

A
  1. Chronic Hep C (most common in US)
  2. Alcohol liver disease (2nd most common)
  3. Nonalcoholic steatohepatitis (becoming more common - obesity)
  4. chronic Hep B (asians and africans)
  5. Other: drug induced, genetics
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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
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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
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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

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7
Q

Cirrhosis risk factors (7)

A
  1. ETOH
  2. IVDU (hep C)
  3. Obesity/NAFLD
  4. Male
  5. Low income/poverty
  6. Low education level
  7. Hispanic

** >80% chronic liver disease is preventable…

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8
Q

What two factors have an additive effect on liver dz?

A
  • elevated BMI

- ETOH

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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
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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

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11
Q

Describe the progression of liver damage

A

Health Liver

  • Fibrotic liver
  • Cirrhotic liver
  • Liver cancer
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12
Q

Fibrotic liver define

A
  • continuous inflammation (hep C) can lead to fibrosis

- formation of scar tissue within the liver

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13
Q

Cirrhotic liver define

A
  • extensive scarring can block flow of blood through liver

- cause liver function to deteriorate over time

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14
Q

Liver cancer define

A
  • Hep C is leading cause

- formation of malignant tumor in liver

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15
Q

6 Pathophysiologic changes dt cirrhosis

A
  1. Unable to process bile- jaundice, scleral icterus, pruritus
  2. Unable to produce enough clotting factors - coagulopathy
  3. sequestration of platelets by spleen - thrombocytopenia
  4. Low albumin production - ascites and edema
  5. Lower ability to metabolize drugs - toxic byproducts, longer half lives
  6. Scarring - portal HTN
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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
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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
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18
Q

When do sx appear in cirrhosis?

A

often non until late stage

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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
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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
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21
Q

Cirrhosis ddx - four

A
  1. other causes of portal HTN
  2. metastatic or multifocal cancer in liver/biliary tree
  3. acute alcoholic hepatitis
  4. drug toxicity (methotrexate, azithioprine)
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22
Q

6 Other possible causes of portal HTN (ddx)

A
  1. portal vein thrombosis, splenic vein thrombosis
  2. lymphoma, splenomegaly
  3. Non-cirrhotic portal fibrosis
  4. Extra hepatic portal vein obstruction
  5. Sarcoidosis
  6. Schistosomiasis
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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
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24
Q

what lab test is the best indication for mortality

A

bilirubin

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25
Q

Lab WU for cirrhosis

  • CBC
  • lipid
  • bleeding studies
A
  • anemia (hemolysis, folate def., splenomegaly)
  • leukopenia
  • decreased platelet
  • low cholesterol
  • prolonged PT/INR, PTT
26
Q

Additional lab tests to perform with Cirrhosis

A
  • 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
Q

Cirrhosis imaging

- what is best initial test

A

Abd US

  • can sometimes note nodules
  • good initial test for masses, screen q6 months for HCC
28
Q

Cirrhosis imaging

- what is doppler US best for?

A

hepatic and portal veins for thrombosis

29
Q

Cirrhosis imaging

- when use MRI?

A
  • fu eval of masses seen on US

- if elevated alpha fetoprotein

30
Q

Cirrhosis imaging

- when use US elastography

A
  • safer than liver biopsy but not widely avail

- measures stiffness of liver tissue to distinguish level of fibrosis

31
Q

Cirrhosis imaging

- when use endoscopic testing?

A
  • EGD
  • r/o esophageal varicies
  • r/o portal HTN gastropathy
32
Q

What is the gold standard for definitive dx of cirrhosis?

A

Liver biopsy

33
Q

Liver biopsy for cirrhosis

A
  • 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
Q

Histology of liver biopsy classic findings

A
  • regenerative nodules

- fibrous tissue bridge portal tracts

35
Q

Histology of liver biopsy in alcoholic liver dz

A
  • steatosis
  • polymorphonuclear leukocyte infiltrate
  • ballooning of hepatocytes
  • Mallory bodies
  • giant mitochondria
36
Q

Histology of liver biopsy in chronic hep B & C

A

periportal lymphocytic inflammation

37
Q

Histology of liver biopsy in NASH

A
  • steatosis
  • polymorphonuclear leukocyte infiltrate
  • Mallory bodies
  • ballooning
    (same as alcoholic but lack of giant mitochondria)
38
Q

Histology of liver biopsy in primary biliary cirrhosis

A
  • polymorphonuclear leukocyte infiltrate
  • portal inflammation
  • loss of bile ducts in portal spaces
39
Q

Histology of liver biopsy in hemochromatosis

A
  • intrahepatic iron stores increased

- hemosiderosis

40
Q

Histology of liver biopsy in alpha1-antitrypsin deficiency

A
  • periodic acid-shift bodies in hepatocytes
41
Q

Histology

A

There are a series of slides to review :)

42
Q

Tx of compensated cirrhosis

A
  • No ETOH, drugs, hepatotoxic drugs

- Antivirals, other meds for hepatitis

43
Q

Tx of compensated cirrhosis due to NASH

A
  • weight loss
  • exercise
  • control lipids/glucose
44
Q

Tx of compensated cirrhosis due to autoimmune

A

prednisone
imuran
6-MP

45
Q

Tx of compensated cirrhosis due to hemochromatosis

A

phlebotomy

46
Q

Tx of compensated cirrhosis due to primary biliary cirrhosis

A

ursodiol

47
Q

Tx of compensated cirrhosis due to Wilson’s disease

A

penicillamine

48
Q

Decomensated cirrhosis complications

A
  • Varices
  • Variceal bleeding
  • Ascites
  • hepatorenal syndrome
  • encephalopathy
  • spontaneous bacterial peritonitis
  • coagulopathy
  • uncompensated - treat complications
49
Q

How to treat varices

A
  • non-selective BB

- preventative band ligation

50
Q

how to treat variceal bleeding

A
  • band ligation, sclerotherapy

- shunting

51
Q

How to treat ascites

A
  • diuretics
  • low Na diet
  • paracentesis
52
Q

How to treat hepatorenal syndrome

A
  • avoid hypovolemia, stop diuretics
  • rehydrate
  • albumin infusion
53
Q

How to treat encephalopathy

A
  • lactulose syrup
  • rifaximin
  • metronidazole
54
Q

How to treat spontaneous bacterial peritonitis

A
  • paracentisis

- abx

55
Q

How to treat coagulopathy

A
  • platelet transfusion

- blood transfusion

56
Q

How to screen for hepatocellular carcinoma

A
  • cirrhosis is the major risk factor
  • US, CT, MRI q 6months
  • alpha fetoprotein (poor sen and spec but still used)
  • liver transplant
57
Q

When screen for esophageal varices

A

at time of cirrhosis dx

  • EGD +/- banding
  • repeat as needed q 1-3 years
58
Q

When paracentesis for ascities

A
  • 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
Q

When to eval for liver transplant

A
  • onset of decompensation (ascites, variceal bleed, encephalopathy)
  • jaundice, liver lesion
  • MELD or Child-Pugh Score
60
Q

Stable cirrhosis - monitoring

A
  • 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
Q

Cirrhosis diet mods

A
  • NO ETOH
  • 4-6 small meals
  • low Na
  • high fiber
  • vitamins and iron
62
Q

Percentage of compensation, decompensation HCC

A

review slide (at end)

GI 2 (11 decks)

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