Lecture 41: Complications of End-Stage Liver Disease Flashcards
What is the difference between compensated and decompensated cirrhosis?
Former = cirrhosis is present but liver functioning well…asymptomatic
Latter = end-stage liver disease, cirrhosis present and liver is NOT functioning well
-symptomatic, indication for liver transplantation
What is portal hypertension due to?
Pressure = R x Q (resistance x blood flow)
Does cirrhosis mean endstage liver disease?
No it does not
You can have cirrhosis and not have ESLD
How can you tell if ascites is due to infection vs. cirrhosis?
Use the Serum albumin ascites gradient (SAAG)
Serum albumin – Ascites albumin = SAAG
If SAAG > 1.1 mg/dL, then cirrhosis and portal hypertension
If SAAG < 1.1 mg/dL, then infection or cancer
What are the major complications of portal hypertension (ESLD)?
- Ascites
- Gastroesophageal varices
- Spontaneous bacterial peritonitis
- Portosystemic Encephalopathy
- Hepatorenal syndrome
Key point: Nitric oxide leads to activation of vasoconstrictors (like RAA system) which leads to impaired sodium excretion
What are causes of ascites?
- malignancy
- TB
- Cirrhosis
- Congenital heart failure
- starvation
What is the treatment for ascites?
- low salt diet
- diuretics (spironolactone)
- large volume paracentesis
- TIPS (transjugular intrahepatic portosystemic shunting
REFER FOR LIVER TRANSPLANT NINJAAA
What are the different degrees of survival in ascites?
- average = 2 years
- refractory ascites = unresponsive to diuretics and requires large volume paracentesis (6 months)
- hepatorenal syndrome = 6 weeks survival
What is hepatorenal syndrome?
Acute renal insufficiency in the setting of end-stage liver disease WITHOUT an alternative diagnosis
- no improvement after stopping diuretics/IV replacement
- look for alternative explanation such as infection, etc
What is the pathophys of hepatorenal syndrome?
Dysregulation of vasoactive hormones
TOO MUCH VASOCONSTRICTION
Associated with refractory ascites
Requires transplant but only have 6 weeks
What are the key characteristics of spontaneous bacterial peritonitis?
When ascites becomes infected
Presentation can be insidious
>250 PMN is diagnostic
Infection is ONLY 1 organism
If you have >1, that means you have perforated bowel
SAAG > 1.1 because you HAVE TO HAVE PORTAL HYPERTENSION
Remember, SAAG <1.1 means there is INFECTION that causes ascites, but it does NOT mean there is bacteria present in the ascites…Nahmean?
What are the symptoms of SBP (spontaneous bacterial peritonitis)?
- fever
- abdominal pain
- mental confusion
- renal failure
What are the most common organisms in spontaneous bacterial peritonitis (SBP)?
- E. coli
- Klebiellla
- Streptococcus
What is the treatment for SBP?
- antibiotics
- give IV albumin to protect kidneys from renal failure
- Need antibiotics to prevent recurrence
What is the quintessential complication of portal hypertension?
Varices
Blood is trying to find an easier route back to heart
Esophageal and gastric varices
What do cherry red spots mean?
It means that shit bled already so you need to keep an eye out for rebleeding varices
What does size of varices tell you?
Larger varices = more likely to bleed
What is the pathophysiology for non-selective beta blocker treatment for esophageal varices?
NON-SELECTIVE beta blocker like propranolol or nadolol
Beta2 is inhibited, thereby allowing for unopposed alpha adrenergic response
Alpha adrenergic response = vasoconstriction of SPLANCHNIC vessels = DECREASED portal inflow = DECREASED portal pressure
What are the treatments for esophageal varices?
- non-selective beta blockers (propranolol and nadolol)
- Octreotide (splanchnic vasoconstrictor)
- Band ligations
- TIPS
- Mechanical tamponade
Why don’t Beta1 blockers work for esophageal varices?
Because Beta 2 is still working, thereby you don’t get vasoconstriction
What is a mechanical tamponade?
Used a balloon to block the bleeding (like placing gauze over bleeding wound)
What are the key characteristics of varices?
- present in many cirrhotics (up to 81%)
1/3 will bleed in a given year
Mortality from initial bleed = 40%
What is TIPS?
Transjugular Intrahepatic Portosystemic Shunting
Surgical procedure that links the portal vein to the HEPATIC VEIN to decrease resistance and thereby decrease portal hypertension
How do you prevent rebleeds?
- follow-up endoscopies with banding
2. NON-selective beta-blockers
