Liver Cirrhosis Flashcards
What is the primary cause of cirrhosis in the Western countries?
Alcoholism
What care the three common genetic diseases that can cause cirrhosis?
Hemochromatosis, Wilson’s Dz (Copper Overload), Alpha 1 Antitrypsin Deficiency
What is the second most cause of cirrhosis in the Western countries?
Metabolic Dz
Other causes of Cirrhosis
Hepatitis B and C, Auto-immune Hepatitis, and Sarcoidosis, Drugs, Toxins, Cryptogenic, Biliary Dz, Venous Outflow Obstruction (very uncommon)
Ongoing ________ results in ongoing liver injury and progression of fibrosis with eventual progression to cirrhosis.
Inflammation
Liver dz characterized pathologically by loss of the normal microscopic lobular architecture with fibrosis and nodular regeneration.
Cirrhosis
I’m looking at a smooth maroon liver in surgery, before doing a histology slide of the cells, what would you think about this liver? What would you expect on a histology slide?
Normal Liver, it will look pretty convoluted and meshlike/brainlike
I’m looking at a nodular discolored liver in surgery, before doing a histology slide of the cells, what would you think about this liver? What would you expect on a histology slide?
Cirrhotic Liver; You will see large spots with surrounding discoloration, etc.
The type of cirrhosis that is associated with NO signs or symptoms of liver dz
Compensated
The type of cirrhosis that is associated with complications/symptoms/signs.
Decompensated
When looking at a liver on a CT, noting some scarring and a more “white” image, would indicate?
Cirrhosis of the liver causing change in architecture. When compared to normal, this looks shrunken.
Patient with yellow skin, what do you think?
JAUNDICE
Patient with yellowing of the eyes is a condition indicative of jaundice is termed?
Icteric Sclerae
When the liver is affected, what can happen in male individuals?
Gynecomastia
A common finding in patients with liver dz/cirrhosis that is seen as a redness of the hands/palms
Palmar Erythema
A common finding in patients with liver dz/cirrhosis that is seen as a localized redness with small vessels.
Spider Angioma
A common finding in patients with liver dz/cirrhosis that is seen as an enlarged preauricular “mass.”
Parotid Enlargement
A common finding in patients with liver dz/cirrhosis that is seen as a torturous elevated vein of the skin termed
Caput Medusa
Define Ascites
Swelling of the abdomen where you can note a severe difference of tympany and dullness when percussing. Dullness would be over the “fluid” portion.
Complications of Cirrhosis (8)
- Portal HTN
- Varices and Variceal Bleeding
- Hyponatremia
- Ascites
- Hepatic Encephalopathy
- Hepatorenal Syndrome
- Hepatopulmonary Syndrome
- Hepatocellular Cancer
The portal venous system begins and ends in the ____________.
Capillaries
What creates the portal vein?
Splenic vein, Superior mesenteric vein, and inferior mesenteric vein.
What is the NORMAL portal vein pressure?
5-6 mm Hg
Normal hepatic sinusoids have ______ resistance to flow
Low
Cirrhotic liver will _______ resistance, making the pressure ______. This pressure change is what causes _________________ to occur.
Create; high; Portal HTN
When is portal HTN “clinically significant”
10+ mm Hg
Dilated collateral veins in the portal-systemic circulation, commonly in the gastric or esophageal veins.
Varices
When do varices start developing? When do these varices cause bleeding?
10+ mm Hg; 12+ mm Hg
Clinical presentation of varices due to portal HTN (since they are internal)
Hematemesis, Hematochezia or melena (usually acute)
Mortality rates from the first bleeding of esophageal varices is about? (Bleeding risk increases about 4% every year in pts with cirrhosis)
25-50% HIGH!!!
What is the likelihood of recurrence in esophageal varices rupture without treatment
70%
If a patient is at high risk for bleeding, what test can you do?
Endoscopy
Varices develop at a rate of
4-12% per year
What is the best way to prevent bleeding?!
Primary prohylaxis!! The goal is to reduce the portal pressure to less than 12 mm Hg. (Treat underlying cause)
What can you give to reduce the portal pressures?
Non-selective Beta Blocker (nadolol, propanolol)! Target HR of 50-60 BPM, decrease HR by 25% of baseline
It is a procedure in which an enlarged vein or a varix (the plural is varices) in the esophagus is tied off or ligated by a rubber band delivered via an endoscope.
Endoscopic Variceal Ligation
Disadvantage of the EVL
Doesn’t affect the portal pressure, just helps prevent bleeding
Risk factors for the first variceal bleed
- Advanced Cirrhosis
- Portal Venous Pressue 12+ mm Hg
- Large Varices
- Stigmata
- Recent stopping of beta blockers
- Volume overload
How do you dx a variceal bleed?
Endoscopy
How do you treat the first variceal bleed?
- Resuscitation
- Vasoactive Drug: Octreotide
- EGD: Banding or Scleropathy
- Rescue Treatment: TIPS
- Should be on antibiotics (Cipro 500 mg IV x 7 days)
What can cause ascites to occur?
Combination of abnormal renal function and alterations in portal and splanchnic circulation.
- Kidney Na+ retention
- Fluid Retention
- Expansion of ECF
- Ascites and Edema formation
How do you treat refractory ascites?
- Repeated paracentesis or shunt (TIPS)
2. Liver transplant
How do you treat mild to moderate Ascites?
- Na+ restriction (2g/day)
2. K+ sparing diuretic +/- loop diuretic (Spironolactor and furosemide)
How do you treat Large Ascites?
Same as mild to moderate. May want therapeutic paracentesis, can consider liver transplant.
Spontaneous infection of ascitic fluid without an intra-abdominal source that can have a high mortality rate if not treated. common in about 10-30% of pts with ascited
Spontaneous Bacterial Peritonitis
How would someone with SBP present?
Abdominal Pain, Fever, Encephalopathy, and a Decline in Renal function
How do you dx SBP?
> 250 mm3 of PMN count in Ascites
How do you treat SBP?
IV 3rd generation cephalosporin
Can occur in cirrhosis and acute liver failure; gut toxins induce acute or recurrent bouts of ________.
Encephalopathy (Hepatic)
Due to toxins escaping the liver and moving throughout the system, a toxin like ammonia can move to the head causing?
Hepatic Encephalopathy
What can Hepatic Encephalopathy cause?
Chronic low grade cerebral edema
A clinical manifestation of hepatic encephalopathy where a patient is not responding would be graded Stage _____ with what mental status?
4; Coma
A clinical manifestation of hepatic encephalopathy where a patient with asterixis would be graded Stage _____ with what mental status?
2; Drowsy
A clinical manifestation of hepatic encephalopathy where a patient with muscle rig would be graded Stage _____ with what mental status?
3; Somnolent
A clinical manifestation of hepatic encephalopathy where a patient with tremors would be graded Stage _____ with what mental status?
1; mildly confused with or without inverted sleep patterns.
When suspected Hepatic Encephalopathy is present, what would you suspect is causing this?
- GI Bleeding
- Hyponatremia
- Infection
- CNS medications
- Constipation
- Non-compliance
How do you treat encephalopathy?
- Lactulose
2. Rifaximin
This medication acidifies the colon so that ammonia (NH3) becomes NH4 and cannot be absorbed.
Lactulose
This medication is a non-absorbable antibiotic used to reduce ammonia producing bacteria in the gut.
Rifaximin
If a patient has hyponatremia, what should you do!?
- D/c spironolactone
2. Water restriction – limiting fluid intake to 500-1000 mL/day
Impaired renal function in a patient with cirrhosis of the liver, commonly vasoconstriction of the renal circulation.
Hepatorenal syndrome (HRS)
Dx of HRS
- Cr > 1.5 or CrCl < 40 mL/mn
- Absence of shock, fluid losses, or nephrotoxic drugs
- No improvements with diuretic withdrawal and volume expansion
- Urine Volume < 500 ml/d
- UNa < 10 mEq/L
Diffuse Dilation of Pulmonary Arterioles and Alveolar Capillaries
Hepatopulmonary Syndrome
What else can help you dx Hepatopulonary Syndrome?
- Bubble Echocardigraphy
2. High shunt fraction (PaO2 < 150 to 200 mm Hg on 100% O2 in the upright position)
Over ___ of patients demonstrated improvement in or resolution of the syndrome by 15 months after orthotopic liver transplantation.
80%
Risk factors the the primary liver cancer (Hepatocellular Carcinoma)
HCV > HBV > Other (Alcohol, Hemochromatosis, Cyptogenic)
Treatment of Hepatocellular Carcinoma
- Sx: Liver Transplant or Resection
- Local/Regional Therapy (TACE)
- Oral Therapy: Sorafenib
Testing for ELD (End Stage Liver Disease)
Creatinine
Total Bilirubin
INR
The higher the number of creatinine, total bili, or INR — indicative of what?
Worsening Liver function!
F/u every 3 months
In a patient with Liver Cirrhosis, you should check for HCC how often?
Every 6 months with AFP and Imaging
AFP! Serum alpha-feto protein
Can be artificially elevated in certain disease processes and does not indicate HCC(e.g. HCV, testicular cancer, pregnancy). AFP greater than 500 usually diagnostic.
