Complications End-Stage Liver Disease

Question 1

What are main causes of cirrhosis and portal hypertension?

Answer 1

Alcoholism, autoimmune hepatitis, viral hepatitis, hemochromatosis, Wilson’s disease, A1AT deficiency, PBC, PSC, toxins, schistosomiasis

Question 2

What is the difference between compensated and decompensated cirrhosis?

Answer 2

Compensated cirrhosis: asymptomatic; liver functioning well

Decompensated cirrhosis=end-stage liver disease; liver not functioning well and liver transplantation should be considered

Question 3

What are the important factors in portal hypertension? (2)

Answer 3

Pressure~Vascular Resistance x Blood flow
P~R*Q

Increase either venous inflow or resistance to portal flow==>portal hypertension

Question 4

What is the main site of resistance?

What is the main site of flow control?

Answer 4

Hepatic sinusoids are main site of resistance

Splanchnic capillaries (feed into portal veil) are main site of flow control

Question 5

What are the major complications of portal hypertension? (5)

Answer 5

Ascites
Gastroesophageal varices
Spontaneous bacterial peritonitis
Portosystemic encephalopathy
Hepatorenal

Question 6

What is the arterial vasodilation theory of ascites pathogenesis?

Answer 6

Arterial vasodilation due to VO leads to effective volume depletion and activation of vasoconstrictors (renin/Angiotensin, ADH)

Impaired Na excretion contributes

Question 7

How do calculate whether ascites is due to portal hypertension or another cause?

Answer 7

Serum Albumin ascites gradient: Serum albumin-albumin in ascites fluid

SAAG>1.1=portal hypertension (cirrhosis/CHF)
SAAG

Question 8

What are the treatment options for ascites?

Answer 8

Low salt diet
Diurects: spironolactone/furosemide
Large volume paracentesis
Transjugular intrehpeatic portosystemic shunting (TIPS): stent to bypass blood around liver

Question 9

What is the survival for ascites?

General, refractory and in hepatorenal syndrome

Answer 9

Average survival for ascites: 2 years
Refractory ascites: 6 months survival
Hepatorenal syndrome: 6 wk survival

Question 10

What is hepatorenal syndrome?

Answer 10

Acute renal insufficiency in setting of end-stage liver disease due to dysregulation of vasoactive hormones (vasoconstriction)

No improvement after stopping diuretics and giving IV fluids

Question 11

What is treatment for hepatorenal syndrome

Answer 11

Dialysis as “bridge” for liver transplant

Liver tx works because the kidney is structurally normal

Question 12

What is spontaneous bacterial peritonitis?

Answer 12

Infection of ascites

Question 13

What is presentation of spontaneous bacterial peritonitis?

How is it diagnosed?

Answer 13

Fever, abdominal pain, mental confusion, renal failure

Dx via paracentesis fluid containing more than 250 PMN cells per cc

Question 14

What are criteria for spontaneous bacterial peritonitis? (2)

Answer 14

1 organism only: most common include E Coli Klebsiella, strep

SAAG>1.1 (must have portal hypertension)

Question 15

What is treatment for spontaneous bacterial peritonitis?

Answer 15

IV abx
IV albumin to protect kidneys

After episode, give abx to prevent recurrence

Question 16

Why do varices arise in setting of portal hypertension?

What are common locations

Answer 16

Blood finds “easier route” back to heart

Observe esophageal varices at GEJ and gastric varices

Question 17

What are predictors for bleeding in esophageal varices? (4)

Answer 17

Size of varies (larger more likely to bleed)
Child class
Pressure gradient
Red signs

Question 18

Epidemiology of varices: prevalence, bleeding, mortality

Answer 18

Varices in 24-81% of cirrhotics
1/3 of these will bleed in a given year
Mortality from bleed is 40-70%
Risk of dying is 10-15% from bleed within 1 yr of diagnosis of large varices

Question 19

What is treatment for esophageal varices?

Answer 19

Screen in all cirrhotics by upper endoscopy

Given beta blocker (propanolol) to prevent bleeding

Question 20

What is treatment for variceal bleeding? (4)

Answer 20

Blood transfusion, ICU

Octreotide: vasoconstrictor to decrease flow
Abx
Band ligation: stop bleeding
TIPS for refractory cases

Question 21

What is mechanical tamponade?

When do you use it?

Answer 21

Inflate balloon to provide mechanical pressure to tamponade bleeding vessel

It is only used for severe, refractory bleeding–it has a high risk of complication: rupture, necrosis of esophageal wall

Question 22

What is hepatic encephalopathy?

Answer 22

Altered mental status (behavior, insomnia, delirium, seizures, coma) as a result of liver disease

Question 23

Describe the pathogenesis of hepatic encephalopathy

Answer 23

Bacter catabolize proteins to ammonia– it is absorbed and bypasses hepatocytes==>it is converted to glutamine in astrocytes and results in increased GABA and decreased glutamate and subsequent cerebral changes

Question 24

What is treatment for hepatic encephalopathy? (4)

Answer 24

Eliminate underlying cause: treat underlying bleeding, constipation, infection
Lactulose: promotes ammonia trapping
Abx: rifaximin==>eliminates bacteria
Protein restriction: decreases ammonia load but most pts protein wasted

Question 25

What should be avoided in Hepatic encephalopathy?

Answer 25

No sedatives

Question 26

What is the MELD score?

Answer 26

Model for End-stage Liver Disease

It provides a 3 month mortality prediction score

Question 27

What is outcomes for liver transplant patients?

Is this different for Hep C patients?

Answer 27

1 year patient survival: 88%
5 year survival: 75%

~10% lower in HCV due to recurrence