End-Stage Liver Disease

Question 0

What is another term for end-stage liver disease?

Answer 0

Decompensated cirrhosis.

Question 1

What are signs of decompensated cirrhosis?

Answer 1

(1) ascites
(2) spontaneous bacterial peritonitis
(3) hepatorenal syndrome
(4) variceal bleeding
(5) hepatic encephalopathy

Question 2

What mechanism contributes most to the progression to decompensated cirrhosis?

Answer 2

Portal hypertension.

Question 3

What is the main site of vascular resistance within the liver?

Answer 3

Hepatic sinusoids.

Question 4

What is the main site of vascular flow control into the liver?

Answer 4

The splanchnic capillaries.

Question 5

What is ascites?

Answer 5

The accumulation of excessive fluid in the peritoneal cavity

Question 6

What is the arterial vasodilation theory of ascites?

Answer 6

(1) arterial vasodilation
(2) effective volume depletion
(3) activation of vasoconstrictors and sodium retention
(4) ascites

Question 7

What are causes of ascites?

Answer 7

(1) cirrhosis
(2) malignancy
(3) congestive heart failure
(4) TB

Question 8

What is SAAG?

Answer 8

Serum albumin ascites gradient. It is equal to the difference between the serum albumin and the albumin in the ascetic fluid.

Question 9

How can SAAG be used to determine the cause of ascites?

Answer 9

A SAAG above 1.1 mg/dL indicates that portal hypertension is the cause. Less could mean infection or cancer.

Question 10

How is ascites treated?

Answer 10

(1) low-salt diet
(2) diuretics (spironolactone, furosemide)
(3) large volume paracentesis
(4) TIPS

Question 11

What is TIPS?

Answer 11

Transjugular intrahepatic portosystemic shunting. A stent is inserted to bypass blood around the liver in refractory cases of ascites.

Question 12

What is hepatorenal syndrome?

Answer 12

Acute renal insufficiency in the setting of end-stage liver disease without an alternative explanation. Often associated with refractory ascites.

Question 13

What is the cause of hepatorenal syndrome in the context of ascites?

Answer 13

Dysregulation of vasoactive hormones leading to too much vasoconstriction.

Question 14

How is hepatorenal syndrome treated?

Answer 14

Liver transplant (kidneys are fine).

Question 15

What are symptoms of spontaneous bacterial peritonitis?

Answer 15

(1) fever
(2) abdominal pain
(3) mental confusion
(4) renal failure

Question 16

How is spontaneous bacterial peritonitis diagnosed?

Answer 16

Paracentesis and fluid analysis.

Question 17

What would you consider if ascitic fluid showed multiple bacterial organisms?

Answer 17

(1) perforated bowel

(2) secondary bacterial peritonitis

Question 18

What are the most commonly found organisms in spontaneous bacterial peritonitis?

Answer 18

(1) E. coli
(2) klebsiella
(3) streptococcus

Question 19

How is spontaneous bacterial peritonitis treated?

Answer 19

(1) antibiotics

2) IV albumin (to protect kidneys

Question 20

How are varices treated?

Answer 20

(1) non-selective beta-blockers (propanolol, nadolol)
(2) octreotide (splanchnic vasoconstrictor)
(3) band ligation
(4) TIPS
(5) mechanical tamponade

Question 21

What is the ammonia hypothesis for hepatic encephalopathy?

Answer 21

(1) Bacteria in the gut catabolize proteins to ammonia.
(2) The ammonia is absorbed and bypasses the cirrhotic liver, entering circulation.
(3) The ammonia leads to astrocyte dysfunction and cerebral changes.

Question 22

What is the primary precipitant of hepatic encephalopathy?

Answer 22

Increased protein load of any kind.

Question 23

How is hepatic encephalopathy treated?

Answer 23

(1) remove precipitants
(2) lactulose (decreases bacterial load)
(3) antibiotics
(4) protein restriction

Question 24

What is lactulose?

Answer 24

A non-absorbed disaccharide that acts as a cathartic, decreasing bacterial load in the GI tract. Used in treating hepatic encephalopathy.