Liver Cirrhosis Flashcards
Why does liver cirrhosis occur and what are the 4 most common causes?
Chronic inflammation leads to hepatocyte damage which results in scar tissue (fibrosis) and nodules forming
Causes:
- ALD
- NAFLD
- HBV
- HCV
What signs might someone with liver cirrhosis present with and why?
Jaundice= raised bilirubin
Hepatomegaly= in early stages because cirrhotic liver shrinks in later stages
Splenomegaly= portal hypertension leads to increased back pressure to splenic vein
Spider naevia= due to increased serum oestrogen due to decreased break down
Palmar erythema= hyperdynamic circulation
Gynaecomastia + testicular atrophy= decreased ostrogen breakdown
Bruising = decreased clotting factors
Ascites= due to portal hypertension and hypoalbuminaemia
Caput medusae= portal hypertension
Asterixis i.e. liver flap= hepatic encephalopathy
What is decompensated cirrhosis? What signs would be present and how would the it be identified on investigation?
Acute deterioration of liver cirrhosis Signs: -hepatic encephalopathy -jaundice -ascites -oesophageal varices -hepatorenal syndrome
Investigations
- derranged LFTs i.e. all markers
- drop in albumin
- increase in INR
- deranged urea and creatinine indicative of heptatorenal syndrome
- hyponatraemia in fluid retention
What imaging can be done to investigate liver cirrhosis and what would you expect find which indicates cirrhosis?
USS Nodularity on surface Corkscrew appearance to arteries due to trying to compensate for reduce portal flow Enlarged portal vein Ascites Splenomegaly
Fibroscan
High frequency waves sent into liver to assess for degree of cirrhosis
What are the 2 prognostic tools which can be used for liver cirrhosis?
Child-Pugh score =severity and prognosis
MELD score = percentage estimate 3 month mortality
What are the most important complications which can arise due to liver cirrhosis?
Malnutrition Portal hypertension + varices haemorrhage Ascites Hepato-renal syndrome Hepatic encephalopathy Hepatocellular carcinoma
Why does liver cirrhosis lead to malnutrition + weight loss?
Protein metabolism and production is effected which effects the availability for muscle growth
Disrupted glycogen storage and release meaning body has to find alternative energy sources by using muscle tissue
Why does portal hypertension occur in liver cirrhosis and what are complications?
Increased resistance to flow due to fibrotic tissue
Varices form at anastomoses between portal system and systemic venous system due to increased back pressure
- gastrooesophageal junction
- ileocaecal junction
- rectum
- anterior abdo wall via umbilical vein= Caput medusae
How can stable varices be managed? Why is this important?
Propranolol= reduces portal hypertension
Elastic band ligation
High flow of blood through varices means that patient can easily bleed out (exsanguinate) if they rupture
What are the resuscitation steps for patient presenting with bleeding oesophageal varices?
Vasopressin analogues= vasocontriction
Vit k and fresh frozen plasma= combats coagulopathy
Prophylactic broad-spectrum antibiotics
Urgent endoscopy = ligation and injection on sclerosant
Why does ascites occur on liver cirrhosis and which type? What are the physiological consequences?
Transudate ascites i.e. low protein content
Increased pressure in portal system leads to movement of fluid out of capillaries into peritoneal cavity due to increased hydrostatic pressure
Drop in circulating volume leads to drop in BP which is detected by the kidneys
RAAS activated to increase renin release which increases aldosterone
Increased NA and H2O retention
How is transudative ascites secondary to liver cirrhosis managed?
Low sodium diet= to prevent sodium excess due to increased retention
Anti-aldosterone diuretics= spironolactone
Paracentesis
Prophylactic antibiotics to prevent against spontaneous bacterial peritonitis (SBP)
What is hepatorenal syndrome and why does it occur in liver cirrhosis?
Portal hypertension leads to stretching of portal vessels and pool of blood here which leads to decreased blood volume in other parts of circulation
Decreased BV causes renal hypotension and stimulates RAAS to cause renal vasoconstriction to try and maintain GFR
BUT leads to hypoperfusion of kidneys= deteriorating kidney function
Why does hepatic encephalopathy occur? How can it be managed?
Build of ammonia (which acts as a toxin) due to impaired metabolism to harmless products
Ammonia is toxic to brain and causes reduced consciousness and confusion
Management
- laxatives to promote excretion before absorbed in gut
- antibiotics (rifaximin) to decrease number of ammonia producing bacteria
The pneumonic “Alcoholics Always Buy Me Very Intoxicating Drinks” can be used to remember the causes of liver cirrhosis?
Alcoholic/non-alcoholic Autoimmune hepatitis Biliary i.e. PBC/PSC Metabolic i.e. hereditary haemochromatosis, Wilson’s disease, Alpha-1 anti-trypsin deficiency Viral hepatitis Idiopathic Drugs i.e. methotrexate
