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GI/Liver > Lec 24 Portal Hypertension > Flashcards

Lec 24 Portal Hypertension Flashcards

1
Q

What characterizes cirrhosis histologically?

A

regenerative nodules surrounded by fibrous tissue

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2
Q

What are the two types of cirrhosis?

A

compensated

decompensated

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3
Q

What is an example of pre-sinusoidal intrahepatic portal htn?

A

schistosomiasis = affects portal venules

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4
Q

What is an example of sinusoidal intrahepatic portal htn?

A

cirrhosis = affects sinusoids

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5
Q

What is an example of post-sinusoidal intrahepatic portal htn?

A

veno-occlusive disease = affects terminal hepatic venules

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6
Q

What are 4 dangerous complications of portal hypertension?

A
  • gastro-esophageal varices
  • hepatic encephalopathy
  • ascites
  • spontaneous bacterial peritonitis
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7
Q

What lab findings suggest cirrhosis?

A
  • low albumin
  • long PT/INR
  • high bilirubin
  • low platelet count
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8
Q

What marks transition from compensated to decompensated cirrhosis?

A

development of variceal hemorrhage, ascites, hepatic encephalopathy or jaundice
- means the patients is at risk of death from liver disease

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9
Q

What is usually the first decompensating event in cirrhosis?

A

ascites first, then jaundice, then encephalopathy

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10
Q

How does decompensation affect survival?

A

significantly shorter survival in decompensated cirrhosis

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11
Q

WHat is initial mech leading to portal hypertension?

A

increase in intrahepatic vascular resistance due to distorted sinusoidal architecture

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12
Q

What is the most common cause of portal hypertension?

A

cirrhosis

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13
Q

What is an example of something that causes post-hepatic portal hypertension?

A

budd-chiari syndrome

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14
Q

What findings in pre-hepatic portal hypertension?

A
  • can still get collaterals and splenomegaly but liver itself looks normal
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15
Q

What findings in pre-sinusoidal portal hypertension?

A

get collaterals + splenomegaly
sinusoids are normal but portal venules clamped down and blood can’t get into sinusoids b/c eggs trapped in portal venules

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16
Q

What findings in liver in post-sinusoidal portal hypertension?

A

centrilobular necrosis of the liver due to ischemia

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17
Q

What is mech of increased portal venous blood flow?

A
  • splanchnic vasodilation due to humoral vasodilatory agents –> leads to reduces systemic vascular resistnace and peripheral arterial pressure –> stimluate Na/H2O reabsorption in kidney to expand plasma volume –> bad circle
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18
Q

What is definition of portal hypertension?

A

portal venous pressure > 10 mmHg

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19
Q

What is management for small verices with no hemorrhage?

A

nothing

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20
Q

What is management for medium/large varices with no hemorrhage?

A
  • B blockers [reduce portal HTN by splanchnic vasoconstriction]
  • endoscopic variceal ligation
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21
Q

What is treatment for variceal bleeding?

A
  • give IV fluid
  • do not overtransfuse
  • give antibiotics
  • vasopressin or octreotide
22
Q

What is action of vasopressin in variceal bleed?

A

splanchinic vasoconstrictor

23
Q

What is action of octreotide in variceal bleed?

A

selectively reduces portal blood flow

24
Q

What is control rate of endoscopic variceal band ligation? rebleeding rate?

A

bleeding controlled in 90%

rebleeding in 30%

25
Q

What is TIPS system?

A

enter shunt through jugular vein into radicle of protal vein –> connects portal system with systemic to decompress the portal system

26
Q

What is treatment for gastric variceal bleed?

A
  • endoscopic cyanoacrylate [glue] injection

- TIPS

27
Q

What is portal hypertensive gastropathy?

A

see cobblestone appearance of mucosa and red signs on endoscopy = reflects congestion in the wal of the stomach

28
Q

What is type A hepatic encephalopathy?

A

associated with acute liver failure

29
Q

What is type B hepatic encephalopathy?

A

assocaited with porto-systemic bypass without intrinsic hepatocellular disease

30
Q

What is type C hepatic encephalopathy?

A

associated wtih Cirrhosis and porto-systemic shunting

31
Q

What is pathogenesis of hepatic encephalopathy?

A

failure to metabolize NH3 in liver –> goes to brain and works on GABA receptors

32
Q

How do you diagnose hepatic encephalopathy?

A

clinical diagnosis by number connection test; EEG

33
Q

What is asterixis?

A

downward drift of hand that you are holding out = hallmark sign of hepatic encephalopathy

34
Q

What is treatment for hepatic encephalopathy?

A
  • lactulose
35
Q

What are some things that put you at risk for hepatic encephalopatyh?

A
  • excess protein
  • TIPS
  • infection
  • diuretics –> dehydration
  • sedative/hypnotics
36
Q

What is the source of fluid in ascites?

A

splanchnic capillary bed and hepatic sinusoids

–> caused by hepatic vein obstruction

–> not cause by portal vein obstruction

37
Q

How do you detect ascites?

A

ultrasound

38
Q

What fluid analysis do you need to do if you see ascites?

A

do PMN count to rule out spontaneous bacterial peritoneal infection

albumin
protein
cultures

39
Q

When should you do diagnostic paracentesis?

A
  • new onset ascites OR admission to hospital
40
Q

What does level of serum ascites albumin gradient tell you?

A

SAAG > 1.1 tesll you its a problem with the liver

SAAG < 1.1 tells you the source is peritoneal

41
Q

What is treatment for ascites?

A

salt restriction and/or diuretics

42
Q

What are mechs that lead to spontaneous bacterial peritonitis?

A
  • decreased immunity
  • intestinal bacterial overgrowth
  • increased intestinal mucosal permeability
43
Q

How do you diagnose spontanoues bacterial peritonitis with ascitic fluid?

A

PMN count > 250

44
Q

What treatment for spontaneous bacterial peritonitis?

A
  • treatment usualy cefotaxime

- avoid aminoglycosides = renal toxicity

45
Q

WHat is effect of giving albumin with antibiotics in SBP?

A

have less renal dysfunction and reduced mortality

46
Q

What can you give to reduce recurrence of spontaneous bacterial peritonitis?

A

norfloxacin

47
Q

What are characteristics of hepatorenal syndrome?

A
  • renal failure in patient with cirrhosis, advanced liver failure, severe sinusoidal portal htn
  • absence of shock, bacterial infection, nephrotoxic drugs
48
Q

What is prognosis of hepatorenal syndrome?

A

> 90% death

49
Q

What is relationship ascites and HRS?

A

all pts with HRS ahve ascites; if no ascites –> suggests renal failure more likely due to other cause

50
Q

What is relationship Na level and HRS?

A

hyponatremia in all pts with HRS; if normal serum Na –> diagnosis of HRS is unlikely

51
Q

What 3 parameters go into MELD score?

A
  • serum total bilirubin
  • serum creatinine
  • INR

GI/Liver (36 decks)

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