Complications of End-Stage Liver Disease

Question 1

Does cirrhosis necessarily imply liver failure?

Answer 1

No.

Question 2

Simple way to distinguish compensated from uncompensated cirrhosis?

Answer 2

Compensated: asymptomatic
Uncompensated: symptomatic
Uncompensated has greatly reduced life expectancy.

Question 3

2 variables affecting pressure in the portal venous system?

Answer 3

Vascular resistance (R) 
Blood flow (Q)

Question 4

What are the 2 capillary beds of the hepatic portal system? Which of the 2 variables affecting portal pressure do each affect, mainly?

Answer 4

Splanchnics - can control blood flow.

Hepatic sinusoids - can affect resistance.

Question 5

What are 3 things that can increase resistance in the liver?

Answer 5

Fibrosis (often in cirrhosis)
Granuloma
Thrombus

Question 6

5 major complications of portal hypertension?

Answer 6

Ascites
Gastroesophageal varices
Spontaneous bacterial peritonitis (SBP)
Portosystemic encephalopathy
Hepatorenal syndrome

Question 7

How does portal hypertension cause ascites?

Answer 7

Portal hypertension activates baroreceptors. - making your body think pressure is too high, causing vasodilation (might be mediated by NO).
This causes reduced perfusion pressure to kidneys, so they think pressure is too low -> renin/angiotensin/aldosterone -> sodium and water retention.
(I think… that this is what some people think…)

Question 8

Other than cirrhosis, what are important causes of ascites?

Answer 8

Malignancy
CHF
Infection (esp. TB, apparently)
Other / mixed
(You want to rule these out with paracentesis.)

Question 9

What is SAAG? Usefulness?

Answer 9

Serum albumin ascites gradient:
SAAG = (Serum albumin) - (ascites albumin)
Gives you clue as to etiology of ascites.

Question 10

What do different values of SAAG tell you?

Answer 10

SAAG > 1.1 mg/dL indicates portal hypertension.

SAAG < 1.1 mg/dL indicates other etiology (eg. infection, cancer)

Question 11

Treatment for ascites?

Answer 11

Low salt diet.
Diuretics (spironolactone + furosemide… try not to mess up K+).
Large volume paracentesis.
TIPS (if refractory).

Question 12

What is TIPS?

Answer 12

Transjugular intrahepatic portosystemic shunting.
A stent is made to connect a hepatic vein with a portal vein, creating a path for blood to bypass the liver.
(less resistance, less portal pressure)

Question 13

What does ascites mean for cirrhosis prognosis?

Answer 13

It’s a bad sign - ascites has average of 2 year survival. So get people on the transplant list.
(refractory ascites has 6mo mean survival)

Question 14

What is hepatorenal syndrome?
Prognosis?
Treatment?

Answer 14

Acute renal insufficiency in end-stage liver disease without an alternative explanation -might be too much vasoconstriction-inducing hormones.
Prognosis is really bad: median survival 6 wks.
Treatment = dialysis until liver transplant.
Interestingly, the kidneys come back to life after liver transplant.

Question 15

What is a spontaneous bacterial peritonitis (SBP) a complication of? Symptoms? What major problem can SBP lead to?

Answer 15

Complication of ascites.
Symptoms: fever, abd pain, confusion, renal failure symptoms.
Can lead to renal failure.

Question 16

How is SBP diagnosed?

How many organisms typically found in SBP?

Answer 16

> 250 PMNs / cc in paracentesis.

Caused by just 1 organism. (in contrast to perforated bowel, eg.)

Question 17

Treatment for SBP?

Answer 17

ABx

IV albumin to protect kidneys.

Question 18

What’s a place other than the esophagus that can have clinically significant varices?

Answer 18

The stomach - usu the fundus.

Question 19

What are some signs that make you more worried that esophageal varices are about to bleed (or have been bleeding)?

Answer 19

Large size
Cherry red spots
Red wales (longitudinal red streaks)

Question 20

What is the mortality rate for an initial episode of bleeding varices?
1 year mortality after diagnosis of large varices?

Answer 20

Initial bleed: 40-70% (depending on if you have Dr. Jaffe there, being a badass)
1 year mortality: 10-15%

Question 21

Drugs that help prevent varices from bleeding?

Answer 21

Non-specific beta-blockers (propanolol or nadolol) and octreotide: decrease splanchnic blood flow.
(Octreotide can also be given acutely during bleed)

Question 22

Should you give ABx when somebody has variceal bleed?

Answer 22

Yes. Infections are common.

Question 23

Procedures to stop variceal bleeding?

Answer 23

Band ligation

Balloon inflation -> mechanical tamponade (more for gastric varices… doesn’t work very well)

Question 24

Can TIPS be used for refractory variceal bleeding?

Answer 24

Yes…

Question 25

What is hepatic encephalopathy (HE)?

Answer 25

Altered mental status that can vary in severity from…

Subtle behavioral change, to insomnia, to delirium/seizures/coma

Question 26

What might be one main toxin in HE?

Answer 26

Ammonia

perhaps other “gut-derived neurotoxins”

Question 27

What biochemical changes does HE cause in the brain? Implication for drug therapy?

Answer 27

Increased GABA, decreased glutamate.

Don’t use GABA-promoting agents (benzos, barbituates).

Question 28

Treatment for HE?

Answer 28

• Identify and avoid precipitants, such as high-protein foods, constipation, tranquilizers, etc.
• ABx: reduce colonic bacteria making ammonia.
• Lactulose (mentioned in small group case)

Question 29

What score is currently used for classifying severity of end stage liver disease / prioritizing transplants?

Answer 29

MELD score - Model for End-Stage Liver Disease