GI - Cirrhosis Complications Flashcards
Causes of liver cirrhosis
Common: Chronic viral hepatitis: Chronic hepatitis B (>60%) Alcoholic liver disease Non-alcoholic fatty liver disease Cryptogenic cirrhosis (15%)
Other:
Autoimmune causes: PSC, autoimmune hepatitis
Metabolic causes: Wilson’s disease, Haemochromatosis
Biliary obstruction: Primary biliary cholangitis, Secondary biliary cirrhosis
Vascular causes: Veno-occlusive disease, Cardiac cirrhosis
List 6 major complications of cirrhosis
Ascites and Spontaneous Bacterial Peritonitis
Hepatorenal syndrome
Variceal bleeding
Encephalopathy
HCC
Pathophysiology of liver cirrhosis
Liver injury results in cytokine production by Kupffer cells and hepatocytes → activates stellate cells in space of Disse
Stellate cells transform into myofibroblast-like cell upon activation, producing
→ Collagen → fibrosis
→ Pro-inflammatory cytokines → hepatocyte damage
→ MMPs → break down normal ECM and replace with scar tissue
Autocrine loops: activated stellate cells produce TGF-β, PDGF and ROS that perpetuates its own activation
Result: progressive hepatic fibrosis with widespread hepatocyte loss and persistent chronic inflammation
S/S of hepatic insufficiency due to liver cirrhosis
Jaundice
Ankle edema, leukonychia - Hypoalbuminaemia
Easy bruising, purpura - Coagulopathy, Thrombocytopenia
Confusion, Flapping tremor - Hepatic encephalopathy
S/S of portal hypertension due to liver cirrhosis
Splenomegaly, Pancytopenia - Easy bruising, anaemic S/S, frequent infection
Caput medusae, Variceal bleeding - UGIB due to portosystemic shunts
Ascites, SBP, hepatic hydrothorax - Splanchnic vasodilation, arterial underfilling and Na retention
Oligoura, Hepatorenal syndrome - vasocontriction from RAAS activation due to arterial underfilling
Endocrine changes associated with liver cirrhosis
Male hypogonadism: due to primary gonad injury or HPG axis suppression
- Testicular atrophy, impotence, infertility, low libido
Feminization, Gynaecomastia: due to increase androgen production and convertion to estradiol
- Gynaecomastia, Inversion of male pubic hair pattern, loss of axillary and pubic hair
Female hypogonadism
- Breast atrophy, Anovulation, Amenorrhea, Low libido
Vascular lesions caused by liver cirrhosis
Pathogenesis
Ddx for each lesion
Spider naevus
Palmar erythema
Due to ↑oestradiol: testosterone ratio
≥3 spider naevi significant, seen mainly in SVC drainage area (i.e. above nipple line)
D/dx for spiders: pregnancy, RA, scleroderma
D/dx for palmar erythema: pregnancy, RA, hyperthyroidism, haem malignancies
S/S cholestasis due to liver cirrhosis
Xanthelasma, Xanthomas
Due to hypercholesterolaemia from impaired biliary cholesterol excretion
Pruritus, Scratch marks
Due to impaired bile acid excretion leading to skin accumulation and pruritus
Differentiate chronic liver failure and liver decompensation
Liver decompensation occurs when metabolic capacity of the liver is exceeded
characterized by development of encephalopathy and ascites
Pathogenesis of ascites due to liver cirrhosis
Cirrhosis leads to portal hypertension
> > Increase portosystemic shunt and vasodilator release»_space; Splanchnic vasodilation (Low pressure due to dilatation, not truly hypovolemia)
> > Decrease total systemic vascular resistance»_space; systemic arterial underfilling (body reacts to apparent hypovolemia, retains water and salt in response)
Results:
Increase RAAS/ SNS for renal tubular reabsorption of sodium - sodium retention, ascites, edema
Increase Vasopressin to reabsorb water in DCT - dilutional hypoNatremia
Lower systemic vasodilator/ Increase local vasoconstriction - Renal vasoconstriction and hypoperfusion, hepatorenal syndrome
Ascites Ddx
Common:
- Malignancy: Primary peritoneal mesothelioma, Peritoneal metastasis, eg. Ca stomach
- Liver cirrhosis and Portal hypertension
- Cardiac failure
- Iatrogenic due to CAPD
Others:
- Hypoalbuminemia: liver decompensation, Nephrotic syndrome, Protein-losing enteropathy, Severe malnutrition
- Peritonitis: pancreatitis, Tuberculous peritonitis
- Hemoperitoneum
Rare:
- Myxedema
- Urological injury
- Abdominal pregnancy
S/S ascites
Asymptomatic: if mild (<1L)
Progressive abdominal distension ± abdominal discomfort
Pressure symptoms:
→ Shortness of breath due to pressure on diaphragm
→ Early satiety due to pressure on stomach
P/E findings:
□ Shifting dullness if >1L
□ Fluid thrill if ascites is marked
□ Features of ↑intra-abdominal pressure: bulging flanks, everted umbilicus, herniae, abdominal striae, divarication of recti, scrotal oedema
Ascites
Diagnostic methods
Imaging:
- USG (1st line): free intraperitoneal fluid (hypoechoic) ± other features of portal HTN
- CT/MRI (2nd line)
Diagnostic Paracentesis
- percutaneous, USG-guided, typically at LLQ
Diagnostic paracentesis
- Indication
- Technique
- All useful exams and differentials
□ Indication: ALL new-onset ascites
□ Technique: percutaneous, USG-guided, typically at LLQ
Appearance:
→ Clear or straw-coloured: uncomplicated cirrhotic ascites
→ Turbid or cloudy: infection
→ Milky (chylous): hyperlipidaemia, TB peritonitis, malignancy (due to lymphatic obstruction)
→ Pink or bloody: traumatic tap, bleeding tendency or malignant ascites
Serum-ascites albumin gradient (SAAG) = serum [Alb] – ascites [Alb]
→ >11g/L → portal hypertension, i.e. cirrhosis, HF, PVT
→ <11g/L → exudative, i.e. malignant, infection, nephrotic syndrome
Cell count and differential:
→ WBC ≥500/mm3 and PMN >250/mm3 diagnostic of SBP
Microbiology:
→ Gram stain and culture
→ AFB smear, culture, ADA
(Cytology for malignant cell, Protein/glucose levels are NOT USEFUL)
Ascites
Management options for mild and severe ascites
General:
- Bedrest - ↓RAAS activity and ↑renal blood flow
- Dietary sodium restriction - 2g/day
- Fluid restriction - 1-1.5L/day for dilutional hypoNa
- Management of underlying liver disease, esp alcohol abstinence
- Avoid drugs affecting renal blood flow to prevent hepatorenal syndrome
Severe:
- Therapeutic paracentesis
- Diuretic therapy
Ascites Diuretic therapy
- Target weight loss
- Types, typical regimen
Target: 1kg/day weight loss
Regimen: PO spironolactone ± furosemide
Types:
K+-sparing diuretics:
→ Spironolactone (Aldactone A)
→ Amiloride (ENaC blocker)
Loop diuretics: alone or add-on K+ sparing diuretics
→ Furosemide (Lasix)
→ Bumetanide (Burinex)
Side effects of diuretic therapy for ascites
Indications to stop diuretic therapy
Spironolactone: hyperkalaemia and tender gynaecomastia in male
Amiloride (ENaC blocker): hyperK, NO gynaecomastia
Furosemide (Lasix): IV injection precipitate acute renal failure
STOP all diuretics if Na <120, progressive renal failure, ↑HE, incapacitating muscle cramps
→ Monitor K: stop Lasix if <3mmol/L, stop spironolactone if >6mmol/L
Therapeutic paracentesis
- Indications
- Target fluid extraction
- Concurrent therapies
indicated for tense or diuretic-resistant ascites, with peripheral edema present
Target: large volume (4-6L) taps
Concurrent Albumin infusion: 6-8g per L fluid removed for large volume taps (≥5L)
Pathogenesis of SBP
- Precipitating factors
- Pathophysiology
- Bacteriology
Precipitating factors of bacteremia:
- Deficiency serum complements
- Poor reticulo-endothelial system function
- GI hemorrhage
- Invasive procedures
Consequence depends on ascitic fluid opsonic activity
→ Poor → SBP
→ Moderate → CNNA (considered an early form of SBP)
→ Good → resolution of bacterascites with macrophage clearance
□ E. coli (43%), K. pneumoniae (11%), Streptococcus spp (28%), Enterobacteriaceae (4%)
