Complications of End Stage Liver Disease

Question 1

Portal venous system pressure calculation

Answer 1

vascular resistance (r) X blood flow (q)

Question 2

Two capillary beds of the portal venous system

Answer 2

splanchnic capillaries and hepatic sinusoids

Question 3

Hallmarks of end stage liver disease

Answer 3

collateral dilation and splenomegaly due to portal hypertension

Question 4

Major complications of portal hypertension (5)

Answer 4

ascites, gastroesophageal varices, spontaneous bacterial peritonitis, portosystemic encephalopathy, hepatorenal syndrome

Question 5

Pathophysiology of ascites

Answer 5

portal hypertension –> baroreceptor activation and neurohormonal alterations (NO) resulting in arterial vasodilation –> drop in blood volume/pressure–> altered renal perfusion –> sodium retention –> intra and extravascular volume overload

Question 6

Etiologies of ascites

Answer 6

cirrhosis > malignancy > CHF > TB > other

Question 7

SAAG

Answer 7

serum album - albumin in ascites fluid

if >1.1 indicates portal hypertension (cirrhosis, CHF)

if <1.1 indicates other etiology (infection, cancer)

Question 8

Tx of ascites

Answer 8

low salt, diuretics (spironolactone, furosemide), paracentesis, TIPS

Question 9

Survival of ascites

Answer 9

2 year

Question 10

Survival of refractory ascites

Answer 10

treatment unresponsive –> 6 months

Question 11

Survival of hepatorenal syndrome

Answer 11

6 weeks

Question 12

Acute renal insufficiency in the setting of end stage liver disease w/o alternative explanation.

Answer 12

hepatorenal syndrome –> no improvement after stopping diuretics, giving iv fluid –> dialysis, liver transplant

due to too much vasoconstriction

Question 13

Dx of spontaneous bacterial peritonitis

Answer 13

SAAG>1.1, >250 PMN in ascites fluid, 1 organism only

Question 14

Most common organisms in bacterial peritonitis

Answer 14

e coli, strep, klebsiella

Question 15

What are the factors that influence bleed risk for varices?

Answer 15

large size, cherry red spots

Question 16

Tx of large varices

Answer 16

propanolol or nadolol (non-selective beta blockers) to prevent bleeding –> 50% reduction in risk for first bleed

Question 17

Why do we give non-selective vs selective beta blockers for varices?

Answer 17

1. beta 2 inhibition in splanchnic capillaries leads to unopposed alpha adrenergic vasoconstriction which reduces inflow of blood to liver (if use a beta 1 blocker, this effect won’t occur) –> beta 2 inhibition is mediated by non-specific blockers
2. octreotide (splanchnic vasoconstricter)
3. blood transfusion
4. antibiotics
5. band ligation
6. tips
7. mechanical tamponade

Question 18

Prevention of rebleeding of varices

Answer 18

follow up endoscopies, banding, beta blockers

Question 19

Pathogenesis of hepatic encephalopathy

Answer 19

gut derived neurotoxins –> absorbed and bypass hepatocytes causing cerebral changes
*bacteria catabolize ammonia which is converted to glutamine –> astrocyte dysfunction // increased GABA, reduced glutamate activity

Question 20

Marker of hepatic encephalopathy

Answer 20

ammonia

Question 21

Precipitants of hepatic encephalopathy

Answer 21

tranquilizers, GI hemorrhage, dietary protein, azotemia

Question 22

Tx of hepatic encephalopathy

Answer 22

tx underlying cause, bleeding, constipation, infection, avoid sedatives, lactulose, antibiotics

Question 23

MOA lactulose

Answer 23

cathartic, decreases bacterial load and inhibits intestinal ammonia production

Question 24

MELD

Answer 24

score based on creatinine, bilirubin, INR (6-40) predicts 3 month mortality

Question 25

Definitive treatment for decompensated cirrhosis

Answer 25

liver transplant