L69 Flashcards
What are the 3 major complications of cirrhosis?
Poor liver fxn… obviously
Portal HTN
Hepatocellular carcinoma
3 consequences of poor liver fxn in synthesis
↓albumin
↑bilirubin -> jaundice
↑prothrombin time = easily bleed
3 consequences of portal HTN
Varices -> bleeding
Ascities
Hepatic encephalopathy
PE findings with cirrhosis: Eyes Skin (4) Stomach + umbilicus (3) Nails Genitals Spleen
- Eyes: scleral icterus (yellow eyes paralleling jaundice)
- Skin:
- Jaundice
- Spider angioma
- Purpura/petechiae
- Edema - Stomach:
- Ascities
- Caput medusae = large veins around umbilicus
- Umbillical hernia - Nails: white nails or clubbing
- Genitals: testicular atrophy
- Splenomegaly
What are the 2 main vessels that feed into the liver?
Hepatic artery
Portal vein
BOTH INTO liver
What is the venous vessel out of the liver?
Hepatic vein
What are the 3 vessels that feed into the portal vein?
Splenic vein
Sup + inf mesenteric veins
The scarring in cirrhosis causes an increase in [what] to increase BP in the liver?
↑intrahepatic resistance
Scar at sinusoids
2 major reasons for cirrhosis in US
Alcohol
Hep C
Explain mechanism for varices and splenomegaly due to cirrhosis
↑P
Portal vein dilates
Blood backs up into tributaries
Spleen gets bigger via splenic vein - compensatory to reduce flow into liver
Coronary vein off portal vein backs up into portal systemic colaterals in INTESTINES = varices
What is sclerotherapy?
Scope down
Inject very caustic substance that forces varice to clot
What is endoscopic ligation?
Scope down
Fire rubber band around bleeding varice -> clot
*Can’t do for gastric varices
Pros of endoscopic ligation > sclerotherapy?
Show to reduce rebleeding rate
Lower mortality
↓complications
What is a TIPS?
Transjugular intrahepatic protosystemic shunt
Shunt between portal -> hepatic vein
SKIP the sinusoids
Connect the high P to low P system to prevent backups associated with portal HTN
What is hepatic encephalopathy?
Due to liver failure or TIPS
Liver not metab neurotoxic substances in the blood
**NH3 shunted to GABA receptors
Change astrocytes
4 stages of hepatic encephalopathy
Confusion
Drowsiness
Somnolence - will wake up but unresponsive
Coma
What 5 things put you at increased risk for hepatic encephalopathy?
- TIPS
- GI bleeding
- Infections
- Sedatives
- Diuretics esp when over-diuresed
Treat ↑NH3 of hepatic encephalopathy + mechanism
Lactulose
↓pH @ colon
NH3 -> NH4
NH4 can’t be reabsorbed -> excreted (usually diarrhea)
1st and 2nd line treatments for uncomplicated ascities
- Diuretics + Na limits
2. Paracentesis
3 treatments for refractory ascites (aka not responding to normal treatment)
- Paracentesis + IV albumin
- TIPS
- Non-TIPS shunt that connects portal vein to systemic venous system
4 complications of untreated uncomplicated ascites
Infection - spontaneous bacterial peritonitis
Tense ascites
Umbilical hernia
Hydrothorax = shift ascites fluid across diaphragm into pleural space
What is the most common cause of hepatocellular carcinoma?
HEP B Otherwise: - Alocholism -> cirrhosis - Hep C - Hemochromatosis - T2D -> fatty liver disease !!
Which pts get screened for HCC? Method of screening.
Cirrhosis
Hep B
US every 6 mo
Criteria to define a HCC lesion
Milan
UCSF criteria is more broad - so even before starting treatment, these pts must have initial therapy to get lesions into Milan criteria
