End Stage Liver Disease

Question 1

What are the two types of damage seen in decompensated cirrhosis?

Answer 1

hepatocellular dysfunction

complications of portal hypertension

Question 2

List clinical signs of hepatocellular dysfunction

Answer 2

Jaundice, cholestasis
fat soluble vitamin deficiency
coagulopathy- bleeding and bruising
hepatic encephalopathy
hypoalbuminemia
hormonal deficiencies

Question 3

List complications of portal hypertension

Answer 3

Ascites
Spontaneous Bacterial Peritonitis
Hepatorenal Syndrome
Variceal Hemorrhage
Hepatic Encephalopathy
Pulmonary Complications of Cirrhosis

Question 4

List pre hepatic causes of portal hypertension

Answer 4

portal vein thrombosis

Question 5

List post hepatic causes of portal hypertension

Answer 5

IVC or hepatic vein occlusion

Question 6

List intrahepatic portal hypertension

Answer 6

• post sinusoidal
• sinusoidal (cirrhosis)
• pre sinusoidal (schistosomiasis)

Question 7

In patients with cirrhosis, portal hypertension leads to shunting and increased capillary hydrostatic pressure, with ______ fluid shift into the peritoneal cavity

Answer 7

transudative

Question 8

The combination of shunting and hepatocellular dysfunction in cirrhosis leads to decreased clearance of endogenous vasodilators such as ______

Answer 8

nitric oxide

Question 9

Splanchnic ______ leads to increased portal inflow, further worsening portal hypertension

Answer 9

vasodilation

Question 10

Splanchnic vasodilation leads to a decrease in the_______, with subsequent reduction in vascular tone and blood pressure causing activation of the RAAS and SNS systems

Answer 10

effective circulating volume (ECV)

Question 11

Activation of RAAS and SNS, total body fluid increases, and portal hypertension eventually overwhelm the lymphatics of the liver and splanchnic system, leading to ______ formation

Answer 11

ascites

Question 12

________ leads to the complication of hepatorenal syndrome

Answer 12

Renal vasoconstriction (in response to perceived low circulating volume)

Question 13

What is the SAAG?

Answer 13

Serum to ascites albumin gradient
= serum albumin- ascites albumin
if > 1.1 then ascites is due to portal hypertension
if < 1.1 then ascites is due to malignancy, TB, bile leak, SLE, etc

Question 14

__________ can be caused by intense renal vasoconstriction in the setting of portal hypertension

Answer 14

acute kidney injury

Question 15

List common precipitants of hepatorenal syndrome

Answer 15

infection esp spontaneous bacterial peritonitis
diuretics
paracentesis
lactulos

Question 16

How can hepatorenal syndrome be distinguished from pre-renal failure

Answer 16

Unlike pre-renal failure, HRS does not respond to volume expansion

Question 17

Describe the formation of varices in portal hypertension

Answer 17

Collateral vessels from, when portal pressure increases, these collaterals dilate and are called varices.

Question 18

Describe the pathophysiology of hepatic encephalopathy

Answer 18

• decreased hepatocellular function- unable to eliminate toxins that cause hepatic encephalopathy
• shunt: portal blood is shunted away from the liver, so liver is not able to detoxify substances
• ammonia and other toxins disturbe neurotransmission and lead to osmotic swelling of astrocytes

Question 19

Splenomegaly leads to ______, which causes consumption and sequestration, initially of platelets leading to thrombocytopenia

Answer 19

hypersplenism

Question 20

List endocrine features of hepatocellular insufficiency

Answer 20

• androgenic failure and feminization
• amenorrhoea, anovulation
• spider angiomata
• palmar erythema

Question 21

Describe the pathology of bone disease in chronic liver disease

Answer 21

immobility and lack of sunlight

disordered hepatic metabolism of vitamin D

Question 22

List infections that people with cirrhosis are at risk for

Answer 22

pneumonia
sepsis secondary to UTI
TB
SBP

Question 23

_______ is a bacterial infection of ascites fluid in a patient with liver disease

Answer 23

spontaneous bacterial peritonitis

Question 24

How is SBP diagnosed?

Answer 24

> 250 PMNs per ml ascitic fluid

Question 25

What malignancies are more common in people with cirrhosis

Answer 25

HCC
hepatoma
cholangiocarcinoma

Question 26

What are causes of death for people with end stage liver disease?

Answer 26

Acute gastrointestinal hemorrhage
Bacterial infection
Multisystem failure, particularly the combination of hepatic and renal failure

Question 27

Describe therapy for acute variceal bleeding

Answer 27

resuscitation- RBCs, FFP
vasoactive medications- octreonide causes splanchnic vasoconstriction and reduces portal flow
antibiotics
PPIs
emergency endoscopy- band ligation or sclerosants if band ligation is not possible

Question 28

_______ causes splanchnic vasoconstriction and reduces portal blood flow

Answer 28

octreonide

Question 29

For patients that fail endoscopic control of variceal hemorrhage_________ can be placed

Answer 29

portosystemic shunts

ex TIPS procedure

Question 30

What are measures used to reduce the risk of rebleeding in patients treated for variceal hemorrhage?

Answer 30

beta blockers- induce splanchnic vasoconstriction

TIPS if refractory bleeding

Question 31

What measures are used to treat hepatorenal syndrome, ascites, and SBP

Answer 31

low salt diet
diuretics esp loop and spironolactone
paracentesis + albumin
TIPS
IV antibiotics + albumin

Question 32

Giving IV albumin along with antibiotics in SBP can reduce mortality and the risk of developing _________

Answer 32

hepatorenal syndrome

Question 33

How is hepatic encephalopathy treated?

Answer 33

avoid or remove precipitants- diuretics, benzos, opioids
lactulose - traps NH3 in form of NH4
rifaximin