Portal HTN and Ascites

Question 1

Two blood supplies to the liver are?

Answer 1

Hepatic artery (30%)
Portal vein (70%)

Question 2

Influence of Cirrhosis on blood flow thorugh the liver?

Answer 2

Cirrhosis causes fibrosis with distortion of the vasculature. Sinusoids turn into capillaries. You get increased blood flow to the stomach and intestines

Question 3

During portal hypertension, venous collaterals form from teh distal esophagus to where

Answer 3

The rectum

Question 4

Anterior collaterals form via which vein?

Answer 4

umbillical

Question 5

Posterior collaterals form via what veins?

Answer 5

Retroperitoneal, you get splenorenal shunts.

Question 6

What is a varice?

Answer 6

Varices are tortuous venous collaterals under high pressure

Question 7

treatment of variceal bleeds

Answer 7

• Volume replacement
• Correct the coagulopathy
• Vasoconstriction of the splanchnic vessels
• decrease blood flow to the stomach and intestines as much as possible
• decrease blood flow via the collaterals

Question 8

What is the classic triad of bad variceal bleeds

Answer 8

1) High Pressure Bleeding
2) Thrombocytopenia- low plateletts
3) Coagulopathy- synthetic impairment of clotting factors

Question 9

Mechanism of ascites

Answer 9

• Increased resistance to portal venous flow
• Increased flow to the portal vein because of the increased flow to stomach and intestine from the arterial side due to vasodilators being where they shouldnt
• Increased lymphatic flow
• LEAKAGE of lymphatic flow from the liver and intestines into peritoneal space (liters of fluid)
• Increased portosystemic shunting of vasodilators leads to increased systemic vasodilation

Question 10

Systemic vasodilation leads to

Answer 10

low blood pressure….kidneys are not perfused

Question 11

When the kidneys are not perfused how do they react?

Answer 11

Increased vasoconstriction in the kidneys

Increased Renin- ANgiotensin- Aldosterone leading to sodium reabsorption and water holding

Question 12

The pattern, starting with ascites is

Answer 12

Ascites forms when you get too much blood backed up in the portal vein and lymph system and fluid begins to leak out into the peritoneum—> Shunting of blood away from the portal system brings vasodilators out into systemic circulation where they are not supposed to be –> You get total body hypoperfusion—> Kidneys react by increasing fluid retention through RAAS—> this worsens ascites and leads to edema

Question 13

Ascites has what effect on kidney function

Answer 13

Decreased renal clearance
Increased sodium retention
Decreased creatinine clearance

Question 14

Know…Ascites can cause so much pressure in the peritoneum that you have difficulty breathing and eating due to pressure on the stomach and diaphragm

Answer 14

ok

Question 15

Fluid can get out of the abdomen, past the diaphragm, and into pleural space which can give you

Answer 15

hepatic hydrothorax

Question 16

Bacterial peritonitis

Answer 16

Any fluid that is undrained can get infected.

Gram negative can get into the peritoneal fluid and cause massive infection. This is an emergency

Question 17

Treatment of ascites

Answer 17

• sodium restriction
• Diuretics
• Treat the liver disease
• Large volume paracentesis

Question 18

So, Chronic portal hypertension causes an increased transvascular pressure gradient between the portal system and the systemic circulation (b/w the portal vein and the hepatic vein). This blood has to get back to the heart though so it will take the path of least resistance,,, portosystemic shunting occurs. As this occurs, vasodilators that our body generally doesn’t see because they are confined to the splanchnic circulation, enter the systemic circulation. This leads to increased blood flow to the splanchnic system arteries yet still tons of resistance on the venous side.

Answer 18

ok

Question 19

Remember, what causes the portal hypertension?

Answer 19

The Cirrhosis of the liver

Question 20

Beta Blockers?

Answer 20

Decrease the risk of variceal bleed by lowering the bloodflow to the splanchnics

Question 21

Child Pugh Classification looks at what?

Answer 21

APE BA

Albumin, Prothrombin Time, Encephalopathy, Bilirubin, Ascites

Child A- Decent function (5-6)
Child B- Not so decent (7-9)
Child C- Dismal (10-15)