Clinical Presentation of Liver Disease

Question 1

What are some complications of chronic liver disease?

Answer 1

• ascites (most common cause is hepatic cirrhosis).
• spontaneous bacterial peritonitis
• portal hypertension
• variceal bleeding
• hepatorenal syndrome
• hepatic encephalopathy
• coagulation abnormalities
• bone disease

Question 2

What causes ascites?

Answer 2

cirrhosis leads to portal hypertension, leading to splanchnic vasodilation, increased pressure, arterial underfilling, and activation of vasoconstrictors and antinatiruretic factors leading to sodium retention and plasma volume expansion

Question 3

What is Meigs syndrome?

Answer 3

triad of ascites, pleural effusion, and benign ovarian tumor (most common fibroma).
*resolves with removal of tumor

Question 4

How do we analyze ascitic fluid?

Answer 4

via PARACENTESIS, and evaluating:

• macroscopic appearance (straw color, turbid, bloody, chylous…).
• cell count
• chemistry profile (protein, albumin, amylase).
• cytology
• gram stain and bacterial culture

Question 5

What gradient will we look at to evaluate ascites?

Answer 5

• serum ascites albumin gradient (SAAG)=
  Serum albumin - albumin level of ascitic fluid.
  *HIGH gradient= > 11 g/L or 1.1 g/dL (think PORTAL HTN)
  *LOW gradient= less than 11/g/L

Question 6

What is the most important initial treatment for ascites?

Answer 6

• salt restriction and diuretic therapy (spironolactone; aldosterone antagonist, and furosemide; loop diuretic).

Question 7

If initial ascites treatment options fail, what then can we do?

Answer 7

• serial therapeutic paracentesis, peritoneovenous shunt, TIPS, or liver transplantation

Question 8

What is transjugular intrahepatic portosystemic shunt (TIPS)?

Answer 8

pass a needle catheter via the transjugular route into the hepatic vein and wedge it there. The needle is then extruded and advanced through the liver parenchyma to the intrahepatic portion of the portal vein and a stent is placed between the portal and hepatic veins; aka you open up the damn to reduce the pressure. This is just done to mitigate the symptoms; not a fix-all situation.
*does not require anesthesia.

Question 9

What is spontaneous bacterial peritonitis (SBP)?

Answer 9

• a common and sever complication of ascites characterized by spontaneous infection of the ascitic fluid WITHOUT an intraabdominal source. Aka you’re getting bacteria into the peritoneal fluid.

Question 10

What is the most common organism of spontaneous bacterial peritonitis?

Answer 10

• E. coli

* treat with Abx (cefotaxime) before cultures even come back if suspicious.

Question 11

How do you diagnose SBP?

Answer 11

• paracentesis with fluid sample having absolute neutrophil count >250/uL

Question 12

How do pts with SBP present?

Answer 12

fever, altered mental status, elevated WBC, and abdominal pain.
*or they may present without any of these.

Question 13

What is NORMAL portal vein pressure vs. portal HTN?

Answer 13

• NORMAL= 5 mm Hg

- portal HTN= >12 mm Hg

Question 14

What are the clinical signs of portal HTN?

Answer 14

esophageal varices, ascites, caput medusae, hemorrhoids, palmar erythema

Question 15

How do you treat esophageal varices due to portal HTN?

Answer 15

• 5% dextrose and colloid solutions until blood is available.
• packed RBCs, FFP, or vitamin K to replenish clotting factors.
• octreotide (somatostatin analog)= reduces splanchnic pressure.
• beta blockers
• sclerotherapy and band ligation

Question 16

What is hepatorenal syndrome?

Answer 16

• increased renal vascular resistance and a reduced systemic vascular resistance, but poorly understood.

Question 17

What are the clinical manifestations of hepatorenal syndrome?

Answer 17

• jaundice
• clubbing
• palmar erythema
• spider nevi
• low BP, wide pulse pressure (difference between systolic and diastolic), and bounding pulses
• decreased GFR (after diuretic withdrawal) and decreased urine output.
• urine osmolality > plasma osmolality

Question 18

What will serum creatinine and creatinine clearance be in hepatorenal syndrome, respectively?

Answer 18

• creatinine= greater than 133 umol/L

- creatinine clearance= less than 40 cc/min

Question 19

What is type 1 hepatorenal syndrome?

Answer 19

• rapid progressive impairment of renal function with doubling of serum creatinine (>221 umol/L in less than 2 weeks).
• Low GFR (creatinine clearance less than 20 cc/min)

Question 20

What is type 2 hepatorenal syndrome?

Answer 20

slower and more insidious than type 1

Question 21

How do you treat hepatorenal syndrome type 1?

Answer 21

• fluids
• diuretics cautiously
• vasopressin analouges or albumin
• dialysis
• TIPS or liver transplant

Question 22

How do you clinically diagnose hepatic encephalopathy?

Answer 22

• mental status change and asterixis
• best marker for maximum cirrhosis progression
• hepatic encephalopathy is required for dx fulminant liver failure.

Question 23

Is there a correlation between ammonia level and severity of disease in hepatic encephalopathy?

Answer 23

NO

Question 24

How do you treat hepatic encephalopathy?

Answer 24

• identify the precipitating factors (low protein diet, stop diuretics…)
• lactulose= non-absorbable disaccharide that causes colonic acidification and elimination of nitrogenous products.
• if that fails, use poorly absorbed antibiotics (neomycin and metronidazole, or rifaximin)

Question 25

Why is bone disease associated with liver disease?

Answer 25

• osteoporosis is common due to malabsorption of vitamin D (due to lack of bile production to absorb the fat soluble vitamin) and decreased liver synthesis of vitamin D.
• can treat with bisphosphonates (controversial)

Question 26

How can you screen a pt suspected to have bone disease due to liver disease?

Answer 26

DEXA scan

Question 27

Why do coagulation abnormalities occur in most pts with liver disease?

Answer 27

• decreased synthesis of clotting factors
• impaired clearance of anticoagulants
• thrombocytopenia from hypersplenism due to portal HTN.