Portal Hypertension Flashcards
Where is the site of increased resistance in cirrhosis?
Sinusoidal
How are pressures in the portal system measured?
HVPG: hepatic venous pressure gradient
What is the formula for HVPG?
HVPG= WHVP-FHVP
At what HVPG is portal hypertension defined? When is there a risk of variceal rupture?
HVPG >5 mmHg is portal hypertension
HVPG >12 mmHg is risk of rupture
What are the 4 locations of varices?
1) Rectal
2) Gastroesophageal
3) Caput Medusae
4) Retro-peritoneal
What is the preventative treatment for varices?
Non-selective beta blockers to decrease cardiac output and portal venous flow
What is the treatment for active variceal bleed?
1) Splanchinic vasoconstriction via vasopressin and octreotide
2) Endoscopy with band ligation (not gastric)
3) Balloon tamponade
4) TIPS (intrahepatic portosystemic shunt)
What are necessary steps to developing ascites secondary to cirrhosis ?
Sinusoidal Hypertension and HVPG > 12 mmHg
What is the mechanism of ascites development?
Increased hydro-static pressure resulting from increased portal flow and pressure
How is ascites defined?
Serum albumin to ascites gradient is >1.1 –> PHTN
What does it mean if Serum albumin to ascites gradient is <1.1?
Etiology is not due to portal hypertension; nephrotic syndrome, tuberculous peritonitis, peritoneal carcinomatosis, and pancreatic source
What is the treatment of ascites?
Diuretics Sodium restriction Therapeutic paracentesis TIPS Transplant
What is Spontaneous bacterial peritonitis?
Peritoneal infection of ascites in the absence of a perforated viscus
How is the diagnosis of SBP made?
> 250 ascitic PMN’s per mm3
What are the common infectious agents of SBP?
Gram neg or gram positive.
E. Coli, Klebsiella pneumoniae, and streptococcal pneumoniae
What is treatment for SBP?
Emergent antibiotics and hospitalization – risk of rapid progression to shock.
1) Provide albumin
2) Increased paracentesis
3) Prophylactic antibiotics
What is the 1 year prognosis of SBP with out transplant?
50%
What is the mechanism of hepatic encephalopathy?
conversion of ammonia to glutamine that is toxic to the brain (neurotransmission and astrocyte swelling)
What is a protective mechanism against hyperammonmia?
Chronicity of liver disease will protect from hyperammonemia via extrahepatic mechanisms of ammonia
What are some reasons that a chronic patient would develop hepatic encephalopathy ?
Dehydration, GI bleed, infection, TIPS
** look for infection**
What is the treatment for hepatic encephalopathy?
Intubation for airway protection
Reversal of infection/precipitating factor
Elimination of nitrogenous sources
What are some ways to remove excess nitrogen sources in hyperammonia
Lactulose, Rifaximin, Metronidazole
What are some pulmonary risks due to cirrhosis?
Portopulmonary Hypertension, Hepatic Hydrothroax, hepatopulmonary syndrome, and restrictive lung because of ascites
What is hepatopulmonary syndrome?
Hypoxemia due to diffusion impairment from alveoli to vasculature due to pathologic pulmonary dilation
How does hepatic disease cause vasodilation in the pulmonary system?
Vasodilators will emanate from hepatic venous drainage into the IVC
What are symptoms of HPS?
(Hepatic pulmonary syndrome)
Platypnea (dyspnea when upright)
Orthodeoxia (desaturation when upright)
due to west zone 3 predominance of vascular dilation
How is HPS (Hepatic pulmonary syndrome) diagnosed?
Late bubbles in a TTE because there is dilation and takes a long time to get through + low DLCO
How is HPS (Hepatic pulmonary syndrome) treated?
Liver transplant will fully reverse the hypoxemia
O2 will override the diffusion limitation
What is the pathophys of portopulmonary HTN?
Vascular injury and inflammation mediated by serum factors and abnormal sheer stress due to hyper-dynamic flow
What is the mPAP nrange to qualify for liver transplant?
25-35 mmHg
Not a good candidate past 35 mmHg
What is the treatment of portopulmonary HTN?
Dobutamine, milrinone, iv epoprostenol (pulmonary dilation)
Liver transplant in which reversal is limited
Results of liver transplant between portopulmonary hypertension vs hepatic pulmonary syndrome
LT will reverse HPS
LT may reverse to some degree PPHTN
What is hepatic hydrothorax?
Transudative pleural effusion due to translocation of ascites
What is a feared complication of hepatic hydrothorax?
Spontaneous bacterial empyema
What is the treatment of hepatic hydrothroax?
Maximize diuretic therapy if renal function can handle
Serial thoracentesis
Gravity drainage via a small bore
TIPS for refractory hydrothorax
What is hepatorenal syndrome?
Function renal damage in the presence of decompensated cirrhosis
What is the treatment of HRS?
splanchnic vasoconstrictors and albumin, norepinephrine, dialysis and liver transplant
What are some metabolic abnormalities experienced with those with chronic liver disease?
Anion gap metabolic acidosis, rapid onset of severe lactic acidosis in the setting of shock
Hypoglycemia
Hyponatremia
How are infections handled in those with chronic liver disease?
Decompensated host is immunocompromised and requires rapid and intense treatment of any bacteria or fungal infection
