Partial 5 - Cirrhosis Flashcards
Cirrhosis definition (Cecil)
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.
What contributes to portal hypertension and intrahepatic shunting? (Cecil)
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.
What leads to development of hepatocellular carcinoma? (Cecil)
Disturbances in cellular regulation and differentiation during hepatocyte regeneration may lead to the development of hepatocellular carcinoma.
Most common causes of cirrhosis in western countries? (Cecil)
Alcohol consumption, hepatitis C virus infection, and nonalcoholic fatty liver disease are the most common causes of cirrhosis in Western industrialized nations,
Most common causes of cirrhosis in Asia and developing countries (Cecil)
Hepatitis B is a major cause in Asia and in developing countries.
Other important causes of Cirrhosis? (Cecil)
Other important causes include: Biliary cirrhosis (primary and secondary) Autoimmune hepatitis Cardiac cirrhosis Inherited diseases Metabolic disorders.
Diagnosis of Cirrhosis (Cecil)
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.
Symptoms of Cirrhosis (Cecil)
Symptoms are often nonspecific and include: Fatigue Malaise Weakness Weight gain or weight loss Anorexia Nausea Increased abdominal girth Abdominal discomfort
Physical findings of Cirrhosis (Cecil)
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.
Hepatocellular dysfunction leads to? (Cecil)
Impaired protein synthesis (hypoalbuminemia and prolongation of prothrombin time)
Hyperbilirubinemia
Low blood urea nitrogen levels
Elevated serum ammonia levels.
Portal hypertension is responsible for? (Cecil)
Thrombocytopenia and leukopenia resulting from splenic sequestration (hypersplenism).
Anemia may result from? (Cecil)
Hypersplenism or gastrointestinal blood loss.
Patients with ascites may have? (Cecil)
Dilutional hyponatremia
Major complications of Cirrhosis (Cecil)
- As a consequence, predominantly of hepatocellular dysfunction:
a. Jaundice
b. Coagulopathy
c. Hypoalbuminemia - As a consequence, predominantly of portal hypertension:
a. Variceal hemorrhage
b. Ascites
c. Spontaneous bacterial peritonitis
d. Hepatorenal syndrome
e. Hepaticencephalopathy
f. Hepatopulmonary syndrome - Hepatocellular carcinoma
Normal Portal venous pressure (Cecil)
5 to 10 mmHg
How does Cirrhosis lead to portal hypertension? Cecil
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)
Variceal bleeding usually causes (Cecil)
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).
Ascites definition (Cecil)
Ascites is the accumulation of excess fluid in the peritoneal cavity.
Two types of Hepatorenal syndrome (Cecil)
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
Treatment for hepatorenal syndrome
Octreotide in combination with midordine
Vasopressin analouges (Terlipressin)
Intavenous albumin
Liver transplantation
Acute hepatic encephalopathy (Cecil)
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
Chronic hepatic encephalopathy (Cecil)
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.
Pathogenesis of Hepatic encephalopathy in the setting of cirrhosis (Cecil)
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.
Clinical manifestations of Hepatic encephalopathy (Cecil)
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)
What is one of the earliest manifestations of Hepatic encephalopathy? (Cecil)
Alteration of the normal sleep-wake cycle
Treatment of hepatic encephalopathy is based on (Cecil)
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
Hepatopulmonary syndrome (Cecil)
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.
