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HEPATOPANCREATOBILIARY MEDICINE > LIVER CIRRHOSIS > Flashcards

LIVER CIRRHOSIS Flashcards

1
Q

What is cirrhosis?

A

The end stage of any progressive liver disease. It is degeneration of cells, inflammation, and fibrous thickening of hepatic tissue.

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2
Q

On examination of a patient with cirrhosis or chronic liver disease, what might you see in the hands?

A 
Palmar erythema
Dupuytren's contracture
Clubbing
Leuconychia
Asterixis 
Muscle wasting
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3
Q

On examination of a patient with cirrhosis or chronic liver disease, what might you see in the eyes?

A

Jaundice
Conjunctival pallor
Xantholasma

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4
Q

On examination of a patient with cirrhosis or chronic liver disease, what might you see on the chest?

A

Gynaecomastia
Spider naevi
Jaundice
Pruritus

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5
Q

On examination of a patient with cirrhosis or chronic liver disease, what might you see in the abdomen?

A

Ascites

Splenomegaly

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6
Q

On examination of a patient with cirrhosis or chronic liver disease, what might you see on general inspection?

A

Peripheral oedema
Bruising
Loss of hair
Jaundice

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7
Q

What are the endocrine features of cirrhosis?

A 
Loss of hair
Testicular atrophy
Parotid enlargement
Gynaecomastia
Amenorrhoea
Loss of libido
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8
Q

What are the neurological features of cirrhosis?

A 
Drowsiness
Confusion
Asterixis
Constructional apraxia
Foetor hepaticus
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9
Q

What investigations would you order in someone who presents with the features of chronic liver disease or cirrhosis?

A 
LFTs
FBC
Clotting factors
Alpha-fetoprotein
Ultrasound
Endoscopy
Liver biopsy
Hepatitis serology
Caeruloplasmin
Autoantibody screen
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10
Q

What would LFTs of someone with cirrhosis typically show?

A

Can be surprisingly normal
Slightly raised ALT and AST
Slightly raised ALP

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11
Q

What would FBC of someone with cirrhosis typically show?

A

Anaemia

Macrocytosis can be direct effect of alcohol or B12/folate deficiency

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12
Q

What would clotting screen show in someone with cirrhosis?

A

Very sensitive indicator of liver dysfunction

Prolonged prothrombin time

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13
Q

What would a positive finding of alpha-fetoprotein likely indicate?

A

Hepatocellular carcinoma

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14
Q

Why would you perform endoscopy in someone with cirrhosis?

A

To check for and treat oesophageal varices

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15
Q

Why is does liver cirrhosis cause a nodular pattern to the liver?

A

The nodules are parts of liver regeneration seperated by scarring (fibrosis)

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16
Q

What is the difference between macronodular and micronodular cirrhosis?

A

Macronodules are more than 3mm in size. They are often the result of hep B or C.

Micronodules are less than 3mm in size. They are more often seen with alcohol abuse.

Mixed picture is often seen.

17
Q

What are the major complications of cirrhosis of the liver?

A

Portal hypertension
Ascites
Hepatic encephalopathy
Hepatorenal syndrome

18
Q

Why does portal hypertension develop in cirrhosis?

A

Vascular resistance is increased due to collagen deposition and fibrosis.

19
Q

What are the major complications of portal hypertension?

A

Ascites

Variceal bleeding

20
Q

Why does ascites occur in cirrhotic patients?

A

Portal hypertension which is aggravated by activation of RAA system leading to water retention. The RAAS is activated because of arterial vasodilation. The arterial vasodilation is secondary to build up of nitric oxide.
Ascites is also aggravated by hypoalbuminaemia.

21
Q

What is spontaneous bacterial peritonitis?

A

A complication of cirrhosis and ascites, which affects 15% of patients admitted with ascites and carries a high mortality rate due to its low detectability. Theory is that bacteria are allowed across the leaky gut wall due to oedematous state of the body.

22
Q

What are the symptoms of spontaneous bacterial peritonitis?

A

Very non-specific and sometimes asymptomatic. Should be suspected in anyone with ascites plus:

Nausea, mild abdominal pain or vomiting
Non-specific clinical deterioration
Fever
Neutrophilia

23
Q

How would you investigate someone with suspected spontaneous bacterial peritonitis?

A

Aspiration of ascitic fluid for culture and looking for neutrophil count of more than 250

24
Q

How do treat someone with spontaneous bacterial peritonitis?

A

A fluoroquinolone (eg ciprofloxacin) or a third generation cephalosporin (eg cefotaxime)

25
Q

What are the signs and symptoms of hepatic encephalopathy?

A 
Confusion
Disorientation
Slurred speech
Convulsions
Coma
Asterixis
Hepatic fetor (sweet-smelling breath due to ketones)
Constructional apraxia (unable to draw a 5-pointed star)
26
Q

What is hepatorenal syndrome?

A

Cirrhosis
Jaundice
Renal failure

Occurs as a result of volume depletion secondary to cirrhosis. Carries a high mortality.

27
Q

How do you manage ascites?

A

Spironolactone is diuretic of choice.

Paracentesis is carried out for symptomatic relief.

28
Q

What are the surgical treatment options for portal hypertension?

A

TIPS - Transjugular Intrahepatic Portosystemic Shunt - introduces shunt between the portal vein and the hepatic vein. High risk of hepatic encephalopathy.

Shunts that drain peritoneal fluid into internal jugular are also available.

Stenting the portal vessel is an option too.

29
Q

What proportion of cirrhotic patients will develop varices?

A

70%

30
Q

What are the clinical features of oesaphageal and gastric varices?

A 
Haematemesis
Melaena
Stigmata of chronic liver disease
Splenomegaly
Features of liver failure
31
Q

What are the three categories of causes of portal hypertension?

A

Pre-sinusoidal
Sinusoidal
Post-sinusoidal

32
Q

What are the pre-sinusoidal causes of portal hypertension?

A

Any blockage of the portal vein before its entry into the liver:

Portal vein thrombosis
Pancreatic disease
Schistosomiasis

33
Q

What are the sinusoidal causes of portal hypertension?

A

Cirrhosis

Congenital hepatic fibrosis

34
Q

What are the post-sinusoidal causes of portal hypertension?

A

Budd-Chiari syndrome
Constrictive pericarditis
Right sided heart failure

35
Q

What is Budd-Chiari syndrome?

A

Occlusion of the hepatic vein leading to the classic triad of ascites, jaundice and hepatomegaly.

36
Q

How do we treat an acute oesophageal bleed?

A

Resuscitation with fluid replacement and eventually blood products.
Correction of coagulopathy with vitamin K
Vasopressin analogue IV (eg terlipressin) - splanchnic vasoconstriction
Antibiotic treatment improves survival
Urgent endoscopy - sclerosant or elastic band ligation.
Balloon tamponade is last resort
Beta-blockers can be used to reduce portal pressure

HEPATOPANCREATOBILIARY MEDICINE (11 decks)

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