Lec 24 Portal Hypertension Flashcards
What characterizes cirrhosis histologically?
regenerative nodules surrounded by fibrous tissue
What are the two types of cirrhosis?
compensated
decompensated
What is an example of pre-sinusoidal intrahepatic portal htn?
schistosomiasis = affects portal venules
What is an example of sinusoidal intrahepatic portal htn?
cirrhosis = affects sinusoids
What is an example of post-sinusoidal intrahepatic portal htn?
veno-occlusive disease = affects terminal hepatic venules
What are 4 dangerous complications of portal hypertension?
- gastro-esophageal varices
- hepatic encephalopathy
- ascites
- spontaneous bacterial peritonitis
What lab findings suggest cirrhosis?
- low albumin
- long PT/INR
- high bilirubin
- low platelet count
What marks transition from compensated to decompensated cirrhosis?
development of variceal hemorrhage, ascites, hepatic encephalopathy or jaundice
- means the patients is at risk of death from liver disease
What is usually the first decompensating event in cirrhosis?
ascites first, then jaundice, then encephalopathy
How does decompensation affect survival?
significantly shorter survival in decompensated cirrhosis
WHat is initial mech leading to portal hypertension?
increase in intrahepatic vascular resistance due to distorted sinusoidal architecture
What is the most common cause of portal hypertension?
cirrhosis
What is an example of something that causes post-hepatic portal hypertension?
budd-chiari syndrome
What findings in pre-hepatic portal hypertension?
- can still get collaterals and splenomegaly but liver itself looks normal
What findings in pre-sinusoidal portal hypertension?
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
What findings in liver in post-sinusoidal portal hypertension?
centrilobular necrosis of the liver due to ischemia
What is mech of increased portal venous blood flow?
- 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
What is definition of portal hypertension?
portal venous pressure > 10 mmHg
What is management for small verices with no hemorrhage?
nothing
What is management for medium/large varices with no hemorrhage?
- B blockers [reduce portal HTN by splanchnic vasoconstriction]
- endoscopic variceal ligation
What is treatment for variceal bleeding?
- give IV fluid
- do not overtransfuse
- give antibiotics
- vasopressin or octreotide
What is action of vasopressin in variceal bleed?
splanchinic vasoconstrictor
What is action of octreotide in variceal bleed?
selectively reduces portal blood flow
What is control rate of endoscopic variceal band ligation? rebleeding rate?
bleeding controlled in 90%
rebleeding in 30%
What is TIPS system?
enter shunt through jugular vein into radicle of protal vein –> connects portal system with systemic to decompress the portal system
What is treatment for gastric variceal bleed?
- endoscopic cyanoacrylate [glue] injection
- TIPS
What is portal hypertensive gastropathy?
see cobblestone appearance of mucosa and red signs on endoscopy = reflects congestion in the wal of the stomach
What is type A hepatic encephalopathy?
associated with acute liver failure
What is type B hepatic encephalopathy?
assocaited with porto-systemic bypass without intrinsic hepatocellular disease
What is type C hepatic encephalopathy?
associated wtih Cirrhosis and porto-systemic shunting
What is pathogenesis of hepatic encephalopathy?
failure to metabolize NH3 in liver –> goes to brain and works on GABA receptors
How do you diagnose hepatic encephalopathy?
clinical diagnosis by number connection test; EEG
What is asterixis?
downward drift of hand that you are holding out = hallmark sign of hepatic encephalopathy
What is treatment for hepatic encephalopathy?
- lactulose
What are some things that put you at risk for hepatic encephalopatyh?
- excess protein
- TIPS
- infection
- diuretics –> dehydration
- sedative/hypnotics
What is the source of fluid in ascites?
splanchnic capillary bed and hepatic sinusoids
–> caused by hepatic vein obstruction
–> not cause by portal vein obstruction
How do you detect ascites?
ultrasound
What fluid analysis do you need to do if you see ascites?
do PMN count to rule out spontaneous bacterial peritoneal infection
albumin
protein
cultures
When should you do diagnostic paracentesis?
- new onset ascites OR admission to hospital
What does level of serum ascites albumin gradient tell you?
SAAG > 1.1 tesll you its a problem with the liver
SAAG < 1.1 tells you the source is peritoneal
What is treatment for ascites?
salt restriction and/or diuretics
What are mechs that lead to spontaneous bacterial peritonitis?
- decreased immunity
- intestinal bacterial overgrowth
- increased intestinal mucosal permeability
How do you diagnose spontanoues bacterial peritonitis with ascitic fluid?
PMN count > 250
What treatment for spontaneous bacterial peritonitis?
- treatment usualy cefotaxime
- avoid aminoglycosides = renal toxicity
WHat is effect of giving albumin with antibiotics in SBP?
have less renal dysfunction and reduced mortality
What can you give to reduce recurrence of spontaneous bacterial peritonitis?
norfloxacin
What are characteristics of hepatorenal syndrome?
- renal failure in patient with cirrhosis, advanced liver failure, severe sinusoidal portal htn
- absence of shock, bacterial infection, nephrotoxic drugs
What is prognosis of hepatorenal syndrome?
> 90% death
What is relationship ascites and HRS?
all pts with HRS ahve ascites; if no ascites –> suggests renal failure more likely due to other cause
What is relationship Na level and HRS?
hyponatremia in all pts with HRS; if normal serum Na –> diagnosis of HRS is unlikely
What 3 parameters go into MELD score?
- serum total bilirubin
- serum creatinine
- INR
