JH IM Board Review - Complications of Liver Disease I Flashcards
Definition - Hepatic FIBROSIS:
A potentially REVERSIBLE wound healing response characterized by an accumulation of extracellular matrix made up of collagen fibrils.
Definition - Cirrhosis:
Defined by:
- Global hepatic fibrosis.
- Nodule formation.
- Reduced hepatic synthetic function.
Overview of cirrhosis - Pathophysiology:
- Chronic hepatic inflammation and injury result in hepatic stellate cell activation and endothelial cell damage.
- Activated stellate cells produce collagen (fibrosis) with subsequent vascular and organ contractions.
Definition of portal HTN:
Portal vein pressure of greater than 8mmHg.
==> MC and most morbid consequence of liver disease and cirrhosis.
Direct portal pressure measurement is highly invasive - Measurement of HVPG (hepatic venous pressure gradient):
HVPG >10 mmHg ==> Development of varices.
HVPG >12 mmHg ==> Complications of portal HTN (eg ascites, variceal hemorrhage).
Classification of portal HTN - Postsinusoidal:
Obstruction DISTAL to hepatic sinusoid:
- EXTRAhepatic (eg IVC obstruction, Budd-Chiari syndrome, RHF).
- INTRAhepatic (eg Venoocclussive disease, alcoholic central hyaline sclerosis).
Classification of portal HTN - Presinusoidal:
Obstruction PROXIMAL to hepatic sinusoids:
- Prehepatic (eg splanchnic AV fistula, splenic vein thrombosis, portal vein thrombosis).
- Hepatic (eg schistosomiasis, sarcoidosis, myeloproliferative disorders).
Classification of portal HTN - Sinusoidal:
- Cirrhosis.
2. Acute alcoholic hepatitis.
Pts with cirrhosis have an …% annual risk of developing varices.
8%. (+ 8% annual rate of progression from small to large varices).
Predictors of variceal hemorrhage:
- Size of varices.
- Child B or C cirrhosis.
- Red “wale” sign seen on endoscopy.
Varices screening:
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.
Varices - Tx - Primary management of varices:
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.
Non selective beta-blockers are NOT recommended for which varices?
SMALL varices without increased risk of bleeding.
==> 1o prophylaxis to prevent the development of varices.
Role of Serial Endoscopic Variceal Ligation (EVL) in varices:
For 1o prevention of bleeding in MEDIUM or LARGE esophageal varices, particularly if a patient cannot tolerate beta-blockers.
General management of acute variceal hemorrhage consists of:
- Intravascular volume resuscitation.
- Maintaining Hb NO HIGHER THAN 8g/dL (to avoid unwanted portal pressure elevation).
- Somatostatin analogues ==> To reduce splanchnic blood volume.
- Short-term phophylactic abx.