Feb 2 - Liver Disease: Cirrhosis Flashcards
What are the nonspecific symptoms of chronic hepatitis?
Anorexia
Nausea
Fatigue
Malaise
What are the hepatic symptoms of chronic hepatitis?
Right upper quadrant pain
Abdominal discomfort
Hepatomegaly/splenomegaly
Cirrhotic and portal hypertension symptoms absent
What are the stages of liver disease?
Fatty liver
-deposits of fat causes liver enlargement
Liver fibrosis
-Scar tissue forms
Cirrhosis
-Growth of connective tissue destroys liver cells
Cirrhosis is characterized by the replacement of the liver tissue with what?
Fibrous scar tissue
Regenerative nodules
What is fibrous scar tissue?
Scar tissue replaces normal healthy tissue, blocking the blood flow throughout the liver
What are regenerative nodules?
Nodules are lumps that occur as a result of process in which damaged tissue is regenerated
What happens when fibrous scar tissue and regenerative nodules replace liver tissue?
There is a loss of liver function
What are three types of cirrhosis?
Alcoholic cirrhosis
Postnecrotic cirrhosis
Biliary cirrhosis
How is alcoholic cirrhosis classified? What causes it?
It is the most common disease form
It has the most substantial loss of liver cells
It’s associated with alcohol abuse
How is postnecrotic cirrhosis classified? What causes it?
It follows hepatitis B or C
It is an inclination for liver cancer
It is caused by chronic infections
How is biliary cirrhosis classified? What causes it?
Obstruction of the biliary duct system
The cause is still unknown at this time but some speculate that is immunological, making it an autoimmune disorder
When the liver is injured due to different causes, alterations occur where?
Cellular response
Extracellular matrix composition
Injury of the liver leads to what?
Activation of stellate cells Accumulation of scar matrix Loss of hepatocyte microvilli Sinusoidal endothelial fenestrae Consequently losing complete hepatic function
What tests are used for grading liver function?
Child-Turcotte-Pugh (CTP) Score
-incorporates albumin, bilirubin, PTT, ascites and encephalopathy
-used to predict 1 and 2 year survival
Model for End-Stage Liver Disease (MELD) Score
-used to predict 3 month survival
What are the three causes of hepatic fibrosis?
Immune response
Wound healing
Fibrosis inducing agents
What are specific symptoms/complications of hepatic fibrosis?
Ascites
Jaundice
Hepatic encephalopathy
What is ascites?
Excess fluid in the peritoneal cavity
What causes ascites?
Portal hypertension
Increased pressure in the portal vein system
What are the consequences of ascites?
Forces fluid out of blood vessels into abdominal cavity
Decreases liver’s ability to filter blood
What causes jaundice?
Increased levels of bilirubin in blood and deposits in body tissue
Damaged liver cells interferes with uptake or excretion of bilirubin
What causes hepatic encephalopathy?
The exact cause is unknown. Decreased liver function (due to cirrhosis) means the liver cannot properly metabolize waste products. Waste products become toxic and enter the blood, travel through the CNS and to the brain (e.g., ammonia)
What constitutional signs and symptoms of cirrhosis?
Fatigue
Malaise
Weight loss
What are GI symptoms of cirrhosis?
Nausea and vomiting
Jaundic
Tender hepatomegaly
What are extrahepatic signs and symptoms?
Palma erythema (red palm) Spider angiomas
What laboratory tests are run for hepatic fibrosis and cirrhosis diagnosis?
Bilirubin is increased
Aminotransferases - Moderate increase in AST and ALT levels (AST>ALT)
Decreased serum albumin levels
What type of diagnostic testing is done for the diagnosis of hepatic fibrosis and cirrhosis?
Cholangiography
CT scan
Ultrasound
Transient elastography
What is the gold standard for heptic fibrosis and cirrhosis diagnosis?
Liver biopsy. It is used if clinical symptoms and lab testing is inconclusive. A small sample of liver tissue is examined for scarring
What are three problems due to portal hypertension?
Increased pressure in the peritoneal capillaries
Portosystemic shunting of blood
Splenomegaly
What does increased pressure in the peritoneal capillaries lead to?
Ascites, which leads to spontaneous bacterial peritonitis
What does portosystemic shunting of blood lead to?
The development of collateral channels, which could lead to caput medusae, hemorrhoids and/or esophageal varices
The shunting of toxins from intestine into general circulation, which could lead to hepatic encephalopathy
What does spenomegaly lead to?
Anemia, thrombocytopenia and leukopenia. Thrombocytopenia can lead to bleeding
What are the symptoms of ascites?
Swelling and discomfort of the abdomen Increased weight Dyspnea Insomnia Trouble walking
How is ascites diagnosed?
Bulging flanks
Flank dullness
Abdominal ultrasound to detect small amount
Ascitic fluid is clear and straw coloured
Turbid ascites may indicate infection
How is ascites treated?
Restriction of salt and water (2 g of salt, 1.2 L of fluids)
Diuretics (spironolactone, furosemide) which leads to reduced aldosterone levels
What is the definition of spontaneous bacterial peritonitis?
When ascitic fluid builds up in the abdomen and becomes infected
What are the symptoms of spontaneous bacterial peritonitis?
Fever Chills Abdominal pain Diarrhea Some patients have no symptoms
What is spontaneous bacterial peritonitis diagnosed?
Paracentesis; ascitic fluid is tested for white blood cells and bacteria levels (if the levels are high, that indicates infection)
How is spontaneous bacterial peritonitis treated?
IV antibiotics (ampicillin, gentamycin) Oral antibiotics to prevent SBP (ciprofloxacin, septra)
Dilation of the collateral channels develop between portal systemic veins that supply what?
The lower rectum (hemorrhoids)
The umbilical veins of the falciform ligament (caput medusae)
Esophagus (esophageal varices)
What is the definition of esophageal varices?
Gastric and esophagus veins dilate forming thin walled varicosities in the submucosa of the esophagus
Why is esophageal varices dangerous?
Cirrhotic liver function typically has insufficient production of clotting, decreased platelets in circulation (hypersplenism) and portal hypertension. As a result, bleeding is likely to occur; it can be severe (it can be fatal). Once varices bleed they tend to re-bleed. The probability that the patient will die from each bleeding is high (30-35%)
What are symptoms of esophageal varices?
Vomiting blood Black and tarry stool Dizziness or fainting Paleness Light-headedness Decreased urine output
How are esophageal varices diagnosed?
Physical examination
-bloody or black stool on rectal exam
-low blood pressure
-rapid heart rate
Tests to determine where the bleeding is coming from and detect active bleeding include
-esophagogastroduodenoscopy
-tube through the nose into the stomach (nasogastric tube)
How is the goal in esophageal varices treatment?
Treatment focuses on lowering portal venous pressure to reduce blood flow to collateral channels
What are pharmacological treatment options for esophageal varices?
Beta-adrenergic blocking drugs (propranolol)
Long acting nitrates (to dilate)
What are surgical treatment options for esophageal varices?
Transjugular intrahepatic shunt (TIPS) (non surgical)
Surgical portosystemic shunt procedures
What is the definition of hepatic encephalopathy?
Accumulation of toxins due to damaged hepatocytes and loss of hepatocyte relationship with blood via the portal vein resulting in impaired brain function
What is hypersplenism? What does it result in?
Enlargement of the spleen reduces the amount of red blood cells, white blood cells and platelets in circulation. It results in anemia, leucopenia, thrombocytopenia
Name the different effects of portal hypertension (8)
Esophageal varices (which leads to hematemesis (throwing up blood) and melena (tarry stool)) Gastropathy (which leads to melena) Splenomegaly Dilated abdominal veins (caput medusae) Ascites Rectal varices (hemorrhoids)
Name the different effects of liver cell failure (12)
Coma
Fetor hepaticus (breath smells like a freshly opened corpse)
Spider nevi (radiating spots caused by estrogen)
Gynecomastia (enlarged breats in men - due to estrogen)
Jaundice
Ascites
Loss of sexual hair
Testicular atrophy
Liver “flap” (coarse hand tremor)
Bleeding tendency (decreased prothrombin)
Anemia (Macrocytic iron deficiency - blood loss)
Ankle oedema
Why would liver transplantation be considered?
Cirrhosis is irreversible/there is no cure.
In far advanced cirrhosis, liver transplantation often is the only option for treatment
