Liver Cirrhosis Flashcards
Anatomy of the Liver
Right and Left Lobes Supplied by hepatic artery and portal vein Drained by hepatic vein 8 anatomical segments Biliary tree
What is the portal vein formed from?
Splenic vein and SMV joining
Portal vein enters liver and divides into R and L branches
Where is blood drained in the liver?
Portal vein -> Central vein -> Hepatic vein -> IVC
What are the immune liver cells?
Kupffer cells
Between blood vessels and sinusoids with other liver cells
What are stellate cells?
Between blood vessels and sinusoids
mesenchymal derived
form collagen when inflammation and scarring
Get damaged in chronic liver failure = portal HTN
What are the functions of the liver?
Protein synthesis = albumin, clotting factors
Carbohydrate Metabolism
Lipid metabolism
Bile production
Immunological function = reticuloendothelial system -> hence sepsis
Hormone & drug metabolism/excretion
Detoxification
What are the 2 components of bile?
Bile pigment = waste product formed from breakdown of RBCs
Bile salt = key product helping lipid breakdown into smaller products for absorption
Why do you get jaundice?
When there is a block in the flow of bile, bile pigments refluxes in circulation = jaundice
Why do you itching?
Reflux of bile salts if blockage of bile
Mechanism of acute liver failure
Hepatocellular dysfunction
Haemodynamic consequences
Symptoms of Hepatocellular dysfunction
Coagulopathy
Jaundice
Encephalopathy
Increased sepsis risk
Haemodynamic symptoms in acute liver failure
As a result of inflammation -> leaky vessels:
Cerebral oedema
Renal failure
Haemodynamic symptoms in chronic liver failure
Due to liver scarring and portal HTN
- splenomegaly
- varices
- ascites
- hepatic encephalopathy
What is the usual pressure of the portal system?
7-10mmHg
Low pressure
How does portal HTN occur?
When liver is scarred in cirrhosis/chronic liver failure the blood from the portal vein struggles to enter this scarred liver. Therefore BP increases inside portal vein.
What happens when there is portal HTN?
> 12mmHg
Causes a back-pressure
Causes opening of collaterals to allow portal vein to empty into systemic circulation (portal-systemic anastomoses)
Portal-systemic anastomoses portal and systemic vessels
Portal circulation is left gastric vein and systemic is azygos vein
Portal circulation is superior rectal vein and systemic is middle and inferior rectal veins
P = paraumbilical vein and S = superficial epigastric vein
P = splenic vein and S = renal vein
Portal-systemic anastomoses sites and condition
Oesophagus = oesophageal varices Fundus of stomach = fundal varices Rectal = rectal varices Paraumbilical = caput medusae Retroperitoneal = splenorenal shunts Also around site of a stoma - peristomal bleeds
What is the mechanism of hepatic encephalopathy?
Bypasses the liver via splenorenal shunts
- normally converts into urea into liver and excreted in urine
- when cirrhosis bypasses liver goes into systemic circulation to the brain = hepatic encephalopathy
- goes into astrocytes = swelling and reduced function
- increases glutamine accumulation
- confusion to coma
What are the clinical features of portal HTN?
- pancytopenia due to splenomegaly
- varices = oesophageal, gastric, rectal
- ascites
- hepatic encephalopathy
Why do you get pancytopenia?
Backpressure of blood in portal system goes to spleen = splenomegaly
Therefore get splenic sequestration -> pancytopenia
Why do you get ascites?
Portal HTN
Splanchnic vasodilation -> decreased circulatory volume -> RAAS activation -> increased sodium retention and renal vasoconstriction
Also low albumin so lower oncotic pressure
What is the commonest porto-systemic site?
Lower Oesophagus
Types of symptoms of chronic liver disease
Asymptomatic for long phase
Cholestatic
Systemic
Decompensation
Cholestatic symptoms
- damage to biliary tree microscopically or macroscopically
- jaundice
- pruritic
- pale stools/dark urine
Define cholestasis
Decrease in bile flow
Why do you get pale stools and dark urine in cholestasis?
Bilirubin not reaching bowel = pale stools
Excess reflux of bilirubin into blood then into kidneys = dark urine
Systemic symptoms
Weight loss
Muscle loss
Fatigue
Decompensation symptoms
- liver is not able to keep up
- jaundice
- fluid retention = swelling feet and abdominal distension
- drowsiness/confusion (encephalopathy)
- GI bleed (varices(
- infection (sepsis)
- coagulopathy
- hepato renal syndrome (failure)
Triggers for decompensation
GI bleed Infection Drugs (diuretics & alcohol abuse) Constipation Progression of liver disease HCC Portal Vein Thrombosis (as sluggish flow)
What to ask about in history of liver patient history?
RF = alcohol, IVDU PMH = liver disease, jaundice DH = medications, all SH = sexual, travel, occupation FH Comorbidities = obesity, diabetes
Signs of asymptomatic compensated liver disease
Xanthelasma Parotid enlargement Spider naevi Gynaecomastia Splenomegaly Liver small or large Clubbing Dupytren's contracture Palmar erythema Testucular atrophy Scratch marks in cholestasis Purpura
General signs of liver disease
Jaundice
Fever
Loss of body hair
Decompensated signs of liver disease
Neurological - hepatic flap, drowsy, coma, disorientation Ascites Shifting dullness Dilated veins on abdomen Oedema at ankles
Spider naevi characteristics
upper chest/back/shoulders
If press center spider will blanch and when let go will fill from center
Complications of liver cirrhosis
Variceal Bleed Ascites Spontaneous Bacterial Peritonitis Hepatorenal syndrome Jaundice
How does a variceal Bleed present?
Haematamesis or malaena
Tx of variceal bleed?
ABCDE
ABs early as increased sepsis risk -> increased portal HTN -> increased bleeding
Terlipressin
Endoscopic therapy = banding, Glue injection
TIPSS
What is terlipressin?
Splanchnic vasoconstrictor
Reduces blood flow during a bleed
Dilates renal veins selectively improving renal perfusion
Prophylaxis of varices?
Beta blockers = carvedilol - reduce portal pressure for primary and secondary prevention
banding for secondary prevention
How to diagnose ascites?
Shifting dullness
peripheral oedema - sacral or ankle
Liver US + doppler (see portal vein flow)
Ascitic tap to rule out spontaneous bacterial peritonitis
Cytology to rule out malignancy causing ascites
What is the portal vein flow direction?
Normally antegrade = towards liver
When liver is scarred = flow reverse = retrograde = portal HTN and cirrhosis
Diagnosis of SBT
Spontaneous bacterial peritonitis
WCC
Cytology
Asitic tap
Treatment of ascites
Low sodium diet
Diuretics = spironolactone and furosemide (difficult if develop renal failure)
Paracentesis (every 2L fluid removes, 200ml of albumin given)
TIPSS (if recurrent)
Liver Transplantation
Spontaneous Bacterial Peritonitis Diagnosis
On ascitic tap:
- WCC>250
- neutrophils >80%
- gram negative rods + enterococcus
Treatment of SBP
IV AB
Human albumin solution
Hepatorenal Syndrome types
Type 1 = due to precipitant = SBP, alcoholic hepatitis
Type 2 = progressive
Tx of hepatorenal syndrome
Human Albumin Solution and Terlipressin
Liver Transplantation
Grades of hepatic encephalopathy
1-4 1 = sleep cycle changes, night insomnia 2-3 = hepatic flap, asterixis 2 = conversation with patient 3 = cannot hold a conversation at all 4 = coma
Precipitants to hepatic encephalopathy?
Constipation Sepsis GI Bleeding Drugs = opoids, benzodiazepines, diuretics Dehydration Portal Vein Thrombosis
Diagnosis of hepatic encephalopathy
Clinical
Hepatic Flap
EEF
Serum ammonia
Tx of hepatic encephalopathy
treat precipitants
Lactulose (1st line)
Rifaxmin (2nd line)
Transplant
What is lactulose
Laxative
Changes of flora of bowel so they produce sugar on breakdown instead of proteins diminishing ammonia production in bowel
Why is pre-hepatic jaundice acholuric?
Bilirubin is produced by Hb breakdown
Bilirubin is attached to albumin as it is unconjugated in circulation so does not pass through the kidneys
When there is haemolysis there is increased Hb breakdown = more bilirubin = jaundice
This is a pre-hepatic cause of jaundice as the cause is haemolysis
Because it is not filtered through the kidneys the urine does not become dark but skin/sclera may be yellow/jaundiced
What is hepatic jaundice like?
When bilirubin reaches the liver it becomes conjugated through microsomes in liver
Conjugated bilirubin is water soluble so gets refluxed into circulation out -> filtered through kidneys -> dark urine
What is post-hepatic jaundice/obstructive jaundice like?
Bilirubin added to bile so gets refluxed into circulation -> through kidneys -> dark urine
Also bile salts are now added to the bile -> itching
Bile does not reach the bowel = pale stools
Hepatic causes of jaundice
Viral Cirrhosis Alcohol NAFLD Autoimmune PBC/PSC Wilsons Haemochromatosis
Post hepatic causes of jaundice
Obstruction
Gallstones
Microscopic disease of biliary tree due to liver disease
Pre hepatic causes of jaundice
Drugs
Inherited disorders
(increased haemolysis)
History of jaundice
Urine colour Pale stools itching abdominal pain onset, duration weight loss anorexia fever liver disease causes and RF
