Liver Failure and Complications of Cirrhosis Flashcards
What are common complications of Cirrhosis?
- Encephalopathy
- Ascites
- SBP
- Varices
- Portal hypertension
How is encephalopathy treated?
- Treat precipitating event (GI bleed, infection etc.) + short term protein restriction
- Oral lactulose
- Oral rifaximin
- Phosphate enema
- Avoid sedatives
What are RF for encphalopathy?
- GI bleed
2. Infection
What is intrahepatic shunting?
- hepatocytes are damaged and now less functional and scar tissue 2. Liver is less effective at removing gut products from the blood, so these products can make their way into the systemic circulation (intrahepatic shunting)
What is extrahepatic shunting?
- some blood from the gut may bypass the liver altogether because of the raised portal pressure
- does this at sited of porto-systemic anastomoses
What gut product impacts neurotransmission?
ammonia (metablosied to glutamine)
Why does GI bleed precipitate encephalopathy?
- GI bleeding is essentially a protein meal
- may precipitate hepatic encephalopathy in cirrhotic patients, because blood proteins will be broken down into ammonia 3. Same for high protein diet
- There are also other precipitants including infection
How do you treat ascites?
- Sodium restriction ±
- Diuretics (fures+spir) ±
- Large volume paracentesis
How do you treat spontaneous bacterial peritonitis?
- Abx (cefuroxime+
metronidazole) - (>250 neutrophils per mm3 ascitic fluid + ascitic fluid culture)
- E.Coli
What is the primary prophylaxis for varices?
- Non-selective β-blocker (if small) e.g. propanolol
2. EVL (if big)
What is the management for ruptures (haemateemsis) varices?
- ABCDE, IV fluids/blood (when Hb<7g/dL)*
- Terlipressin + Abx
- EVL (immediately after resuscitation)
What is the secondary prophylaxis for varices?
- Non-selective β-blocker (to replace terlipressin after 2-5 days)
- TIPS procedure (when EVL + β-blocker fails to prevent)
- uncontrollable bleeding use balloon tamponade/metal mesh stent
What is Liver failure?
severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy
What can cause acute liver failure?
paracetamol overdose (transaminitis +++) (50% of ALF)/ viral hepatitis
What can cause acute-on-chronic liver failure?
acute decompensation in patients with chronic liver disease
What Ix are used for liver failure?
Identify cause (viral serology, paracetamol levels, etc.)
What is the management of liver failure?
- See acute med for paracetamol overdose
- Treat complications
- Liver transplant
What is hyperacute liver failure?
Encephalopathy <7 days after onset of jaundice
What is acute liver failure?
Encephalopathy 1-4 weeks after onset of jaundice
What is subacute liver failure?
Encephalopathy 4-12 weeks after onset of jaundice
What is acute on chronic liver failure?
acute decompensation in patients with chronic liver disease
What is normal portal circulation?
- when blood from the spleen (splenic vein) and the bowels (inferior and superior mesenteric veins) travel through the liver via the portal vein
- Blood from these places is full of ingested toxins/pathogens
- Only once passing through the liver (where it is detoxified/cleaned) can the blood become part of the systemic circulation via the IVC
What happens when there is a blockage to blood through the liver e.g. due to cirrhosis or clot in hepatic vein (Budd Chiari)?
- backlog of blood into the portal system, raising portal pressure
- Eventually, this blood (which has not yet been processed by the liver) can transfer across from the portal into the systemic circulation at sites of port-systemic anastomoses
What is portal hypertension?
increase pressure in portal vein due to cirrhosis (of any cause)
What happens in portal hypertension? What are key sites?
• Blood flows from portal to systemic circulation (porto-systemic anastamosis), sites of this:
- Lower eosophagus
- Anal canal
- Umbilicus
- Splenorenal
What does portal hypertension lead to?
- Distended veins (varices)
- Ascites
- Splenomegaly
