Partial 5 - Cirrhosis

Question 1

Cirrhosis definition (Cecil)

Answer 1

Cirrhosis is the irreversible end result of a variety of inflammatory, toxic, metabolic, and congestive insults to the liver. These insults lead to the formation of interconnecting bands of fibrous tissue that surround nodules consisting of foci of regenerating hepatocytes.

Question 2

What contributes to portal hypertension and intrahepatic shunting? (Cecil)

Answer 2

The disruption of the normal hepatic lobular architecture distorts the vascular bed and contributes to portal hypertension and intrahepatic shunting. Normal hepatocyte function is disturbed by the resulting inadequacy of blood flow and ongoing inflammatory, toxic, or metabolic damage to hepatocytes.

Question 3

What leads to development of hepatocellular carcinoma? (Cecil)

Answer 3

Disturbances in cellular regulation and differentiation during hepatocyte regeneration may lead to the development of hepatocellular carcinoma.

Question 4

Most common causes of cirrhosis in western countries? (Cecil)

Answer 4

Alcohol consumption, hepatitis C virus infection, and nonalcoholic fatty liver disease are the most common causes of cirrhosis in Western industrialized nations,

Question 5

Most common causes of cirrhosis in Asia and developing countries (Cecil)

Answer 5

Hepatitis B is a major cause in Asia and in developing countries.

Question 6

Other important causes of Cirrhosis? (Cecil)

Answer 6

Other important causes include: 
Biliary cirrhosis (primary and secondary)
Autoimmune hepatitis
Cardiac cirrhosis
Inherited diseases
Metabolic disorders.

Question 7

Diagnosis of Cirrhosis (Cecil)

Answer 7

Patients with cirrhosis are often asymptomatic, and the diagnosis is incidentally established at the time of physical examination, laboratory testing, or radiologic testing for unrelated purposes. Alternatively, patients may present with specific complications of cirrhosis such as variceal bleeding, ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy.

Liver biopsy is considered the gold standard for the diagnosis of cirrhosis.

Question 8

Symptoms of Cirrhosis (Cecil)

Answer 8

Symptoms are often nonspecific and include:
Fatigue
Malaise
Weakness
Weight gain or weight loss
Anorexia
Nausea
Increased abdominal girth
Abdominal discomfort

Question 9

Physical findings of Cirrhosis (Cecil)

Answer 9

Physical findings include: 
Jaundice
Abnormal liver span or consistency
Splenomegaly
Ascites
Lower extremity edema
Spider angiomas
Palmar erythema
Nail changes (Terry nails— proximal nail plate discoloration; and Muehrcke lines—white horizontal lines)
Gynecomastia
Caput medusae
Asterixis
Testicular atrophy.

Question 10

Hepatocellular dysfunction leads to? (Cecil)

Answer 10

Impaired protein synthesis (hypoalbuminemia and prolongation of prothrombin time)
Hyperbilirubinemia
Low blood urea nitrogen levels
Elevated serum ammonia levels.

Question 11

Portal hypertension is responsible for? (Cecil)

Answer 11

Thrombocytopenia and leukopenia resulting from splenic sequestration (hypersplenism).

Question 12

Anemia may result from? (Cecil)

Answer 12

Hypersplenism or gastrointestinal blood loss.

Question 13

Patients with ascites may have? (Cecil)

Answer 13

Dilutional hyponatremia

Question 14

Major complications of Cirrhosis (Cecil)

Answer 14

1. As a consequence, predominantly of hepatocellular dysfunction:
   a. Jaundice
   b. Coagulopathy
   c. Hypoalbuminemia
2. As a consequence, predominantly of portal hypertension:
   a. Variceal hemorrhage
   b. Ascites
   c. Spontaneous bacterial peritonitis
   d. Hepatorenal syndrome
   e. Hepaticencephalopathy
   f. Hepatopulmonary syndrome
3. Hepatocellular carcinoma

Question 15

Normal Portal venous pressure (Cecil)

Answer 15

5 to 10 mmHg

Question 16

How does Cirrhosis lead to portal hypertension? Cecil

Answer 16

In cirrhosis, the distortion of hepatic architecture by fibrous tissue and regenerative nodules, as well as a dynamic component caused by an increase in intrahepatic vascular tone, leads to increased resistance to portal venous flow, resulting in increased portal venous pressure (>10 mm Hg)

Question 17

Variceal bleeding usually causes (Cecil)

Answer 17

Painless hematemesis, melena, or hematochezia, which typically leads to hemodynamic compromise, further aggravated by impaired hepatic synthesis of coagulation factors (from hepatocellular dysfunction) and thrombocytopenia (from hypersplenism).

Question 18

Ascites definition (Cecil)

Answer 18

Ascites is the accumulation of excess fluid in the peritoneal cavity.

Question 19

Two types of Hepatorenal syndrome (Cecil)

Answer 19

Type 1 is characterized rapidly progressive renal failure that occurs within 2 weeks and is associated with dismal prognosis

In type 2, renal dysfunction occurs more slowly and is associated with better prognosis

Question 20

Treatment for hepatorenal syndrome

Answer 20

Octreotide in combination with midordine
Vasopressin analouges (Terlipressin)
Intavenous albumin
Liver transplantation

Question 21

Acute hepatic encephalopathy (Cecil)

Answer 21

Acute hepatic encephalopathy usually occurs in the setting of fulminant hepatic failure. Cerebral edema plays an important role in this setting, progression to coma is common, and mortality is extremely high

Question 22

Chronic hepatic encephalopathy (Cecil)

Answer 22

Chronic hepatic encephalopathy usually occurs in the setting of cirrhosis and is often reversible. It commonly produces disturbances in the sleep-wake cycle, subtle neurologic dysfunction, and behavioral changes.

Question 23

Pathogenesis of Hepatic encephalopathy in the setting of cirrhosis (Cecil)

Answer 23

The pathogenesis of hepatic encephalopathy in the setting of cirrhosis is thought to involve the inadequate hepatic removal of predominantly nitrogenous compounds or other toxins ingested or formed in the gastrointestinal tract.

Question 24

Clinical manifestations of Hepatic encephalopathy (Cecil)

Answer 24

Disturbances of higher neurologic function (e.g., intellectual and personality disorders, dementia, inability to copy simple diagrams [constructional apraxia], disturbance of consciousness)

Disturbances of neuromuscular function (e.g., asterixis, hyperreflexia, myoclonus

Rarely a Parkinson-like syndrome and progressive paraplegia.

Fetor hepaticus (passing of thiols directly to the lungs)
Aterixis (a hand flapping tremor)

Question 25

What is one of the earliest manifestations of Hepatic encephalopathy? (Cecil)

Answer 25

Alteration of the normal sleep-wake cycle

Question 26

Treatment of hepatic encephalopathy is based on (Cecil)

Answer 26

Identifying and addressing precipitating factors, short-term restricting dietary protein, reducing and eliminating substrates for the generation of nitrogenous compounds, and preventing ammonia absorption from the bowel

Question 27

Hepatopulmonary syndrome (Cecil)

Answer 27

Hepatopulmonary syndrome occurs in 10% to 30% of patients with cirrhosis and is characterized by gas exchange abnormalities (increased alveolar-arterial gradient and hypoxemia) as a result of intrapulmonary vascular dilation. The vascular dilation leads to impaired oxygen transfer from alveoli to the central stream of red blood cells within capillaries, resulting in a functional intrapulmonary right-to-left shunt that improves with 100% oxygen.