Complications of End-Stage Liver Disease Flashcards
Does cirrhosis necessarily imply liver failure?
No.
Simple way to distinguish compensated from uncompensated cirrhosis?
Compensated: asymptomatic
Uncompensated: symptomatic
Uncompensated has greatly reduced life expectancy.
2 variables affecting pressure in the portal venous system?
Vascular resistance (R) Blood flow (Q)
What are the 2 capillary beds of the hepatic portal system? Which of the 2 variables affecting portal pressure do each affect, mainly?
Splanchnics - can control blood flow.
Hepatic sinusoids - can affect resistance.
What are 3 things that can increase resistance in the liver?
Fibrosis (often in cirrhosis)
Granuloma
Thrombus
5 major complications of portal hypertension?
Ascites Gastroesophageal varices Spontaneous bacterial peritonitis (SBP) Portosystemic encephalopathy Hepatorenal syndrome
How does portal hypertension cause ascites?
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…)
Other than cirrhosis, what are important causes of ascites?
Malignancy CHF Infection (esp. TB, apparently) Other / mixed (You want to rule these out with paracentesis.)
What is SAAG? Usefulness?
Serum albumin ascites gradient:
SAAG = (Serum albumin) - (ascites albumin)
Gives you clue as to etiology of ascites.
What do different values of SAAG tell you?
SAAG > 1.1 mg/dL indicates portal hypertension.
SAAG < 1.1 mg/dL indicates other etiology (eg. infection, cancer)
Treatment for ascites?
Low salt diet.
Diuretics (spironolactone + furosemide… try not to mess up K+).
Large volume paracentesis.
TIPS (if refractory).
What is TIPS?
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)
What does ascites mean for cirrhosis prognosis?
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)
What is hepatorenal syndrome?
Prognosis?
Treatment?
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.
What is a spontaneous bacterial peritonitis (SBP) a complication of? Symptoms? What major problem can SBP lead to?
Complication of ascites.
Symptoms: fever, abd pain, confusion, renal failure symptoms.
Can lead to renal failure.
How is SBP diagnosed?
How many organisms typically found in SBP?
> 250 PMNs / cc in paracentesis.
Caused by just 1 organism. (in contrast to perforated bowel, eg.)
Treatment for SBP?
ABx
IV albumin to protect kidneys.
What’s a place other than the esophagus that can have clinically significant varices?
The stomach - usu the fundus.
What are some signs that make you more worried that esophageal varices are about to bleed (or have been bleeding)?
Large size
Cherry red spots
Red wales (longitudinal red streaks)
What is the mortality rate for an initial episode of bleeding varices?
1 year mortality after diagnosis of large varices?
Initial bleed: 40-70% (depending on if you have Dr. Jaffe there, being a badass)
1 year mortality: 10-15%
Drugs that help prevent varices from bleeding?
Non-specific beta-blockers (propanolol or nadolol) and octreotide: decrease splanchnic blood flow.
(Octreotide can also be given acutely during bleed)
Should you give ABx when somebody has variceal bleed?
Yes. Infections are common.
Procedures to stop variceal bleeding?
Band ligation
Balloon inflation -> mechanical tamponade (more for gastric varices… doesn’t work very well)
Can TIPS be used for refractory variceal bleeding?
Yes…
What is hepatic encephalopathy (HE)?
Altered mental status that can vary in severity from…
Subtle behavioral change, to insomnia, to delirium/seizures/coma
What might be one main toxin in HE?
Ammonia
perhaps other “gut-derived neurotoxins”
What biochemical changes does HE cause in the brain? Implication for drug therapy?
Increased GABA, decreased glutamate.
Don’t use GABA-promoting agents (benzos, barbituates).
Treatment for HE?
- Identify and avoid precipitants, such as high-protein foods, constipation, tranquilizers, etc.
- ABx: reduce colonic bacteria making ammonia.
- Lactulose (mentioned in small group case)
What score is currently used for classifying severity of end stage liver disease / prioritizing transplants?
MELD score - Model for End-Stage Liver Disease
