JH IM Board Review - Complications of Liver Disease I Flashcards

1
Q

Definition - Hepatic FIBROSIS:

A

A potentially REVERSIBLE wound healing response characterized by an accumulation of extracellular matrix made up of collagen fibrils.

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2
Q

Definition - Cirrhosis:

A

Defined by:

  1. Global hepatic fibrosis.
  2. Nodule formation.
  3. Reduced hepatic synthetic function.
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3
Q

Overview of cirrhosis - Pathophysiology:

A
  1. Chronic hepatic inflammation and injury result in hepatic stellate cell activation and endothelial cell damage.
  2. Activated stellate cells produce collagen (fibrosis) with subsequent vascular and organ contractions.
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4
Q

Definition of portal HTN:

A

Portal vein pressure of greater than 8mmHg.

==> MC and most morbid consequence of liver disease and cirrhosis.

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5
Q

Direct portal pressure measurement is highly invasive - Measurement of HVPG (hepatic venous pressure gradient):

A

HVPG >10 mmHg ==> Development of varices.

HVPG >12 mmHg ==> Complications of portal HTN (eg ascites, variceal hemorrhage).

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6
Q

Classification of portal HTN - Postsinusoidal:

A

Obstruction DISTAL to hepatic sinusoid:

  1. EXTRAhepatic (eg IVC obstruction, Budd-Chiari syndrome, RHF).
  2. INTRAhepatic (eg Venoocclussive disease, alcoholic central hyaline sclerosis).
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7
Q

Classification of portal HTN - Presinusoidal:

A

Obstruction PROXIMAL to hepatic sinusoids:

  1. Prehepatic (eg splanchnic AV fistula, splenic vein thrombosis, portal vein thrombosis).
  2. Hepatic (eg schistosomiasis, sarcoidosis, myeloproliferative disorders).
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8
Q

Classification of portal HTN - Sinusoidal:

A
  1. Cirrhosis.

2. Acute alcoholic hepatitis.

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9
Q

Pts with cirrhosis have an …% annual risk of developing varices.

A

8%. (+ 8% annual rate of progression from small to large varices).

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10
Q

Predictors of variceal hemorrhage:

A
  1. Size of varices.
  2. Child B or C cirrhosis.
  3. Red “wale” sign seen on endoscopy.
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11
Q

Varices screening:

A

Endoscopy is the key to the diagnosis of varices.

==> Screening every 1 to 3 years is recommended for pts with cirrhosis.

==> Frequency of screening increases with severity of liver disease.

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12
Q

Varices - Tx - Primary management of varices:

A

Non selective beta-blockers (eg propranolol, nadolol) ==>

Recommended for the 1o prevention of bleeding in SMALL varices with increased risk of bleeding (Eg Child B and C, red wale marks) and in ANY medium or large varices.

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13
Q

Non selective beta-blockers are NOT recommended for which varices?

A

SMALL varices without increased risk of bleeding.

==> 1o prophylaxis to prevent the development of varices.

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14
Q

Role of Serial Endoscopic Variceal Ligation (EVL) in varices:

A

For 1o prevention of bleeding in MEDIUM or LARGE esophageal varices, particularly if a patient cannot tolerate beta-blockers.

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15
Q

General management of acute variceal hemorrhage consists of:

A
  1. Intravascular volume resuscitation.
  2. Maintaining Hb NO HIGHER THAN 8g/dL (to avoid unwanted portal pressure elevation).
  3. Somatostatin analogues ==> To reduce splanchnic blood volume.
  4. Short-term phophylactic abx.
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16
Q

3 measures for acute variceal bleeding:

A
  1. Urgent endoscopic evaluation and therapy.
  2. TIPS for uncontrolled or recurrent variceal hemorrhage despite endoscopy.
  3. Balloon tamponade can be an effective but temporary (less than 24h) control of hemorrhage.
17
Q

After recovering from acute variceal hemorrhage, 2o prophylaxis using …?

A
  1. Non selective beta-blockers.
  2. Serial Endoscopic Variceal Ligation (EVL) is recommended.
  3. If bleeding still occurs, consider TIPS.
18
Q

Variceal bleeding - What is the goal of HVPG?

A

Less than 12mmHg or at least 20% below baseline levels.