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GI Module > Portal Hypertension > Flashcards

Portal Hypertension Flashcards

1
Q

Where is the site of increased resistance in cirrhosis?

A

Sinusoidal

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2
Q

How are pressures in the portal system measured?

A

HVPG: hepatic venous pressure gradient

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3
Q

What is the formula for HVPG?

A

HVPG= WHVP-FHVP

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4
Q

At what HVPG is portal hypertension defined? When is there a risk of variceal rupture?

A

HVPG >5 mmHg is portal hypertension

HVPG >12 mmHg is risk of rupture

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5
Q

What are the 4 locations of varices?

A

1) Rectal
2) Gastroesophageal
3) Caput Medusae
4) Retro-peritoneal

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6
Q

What is the preventative treatment for varices?

A

Non-selective beta blockers to decrease cardiac output and portal venous flow

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7
Q

What is the treatment for active variceal bleed?

A

1) Splanchinic vasoconstriction via vasopressin and octreotide
2) Endoscopy with band ligation (not gastric)
3) Balloon tamponade
4) TIPS (intrahepatic portosystemic shunt)

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8
Q

What are necessary steps to developing ascites secondary to cirrhosis ?

A

Sinusoidal Hypertension and HVPG > 12 mmHg

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9
Q

What is the mechanism of ascites development?

A

Increased hydro-static pressure resulting from increased portal flow and pressure

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10
Q

How is ascites defined?

A

Serum albumin to ascites gradient is >1.1 –> PHTN

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11
Q

What does it mean if Serum albumin to ascites gradient is <1.1?

A

Etiology is not due to portal hypertension; nephrotic syndrome, tuberculous peritonitis, peritoneal carcinomatosis, and pancreatic source

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12
Q

What is the treatment of ascites?

A 
Diuretics 
Sodium restriction 
Therapeutic paracentesis 
TIPS 
Transplant
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13
Q

What is Spontaneous bacterial peritonitis?

A

Peritoneal infection of ascites in the absence of a perforated viscus

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14
Q

How is the diagnosis of SBP made?

A

> 250 ascitic PMN’s per mm3

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15
Q

What are the common infectious agents of SBP?

A

Gram neg or gram positive.

E. Coli, Klebsiella pneumoniae, and streptococcal pneumoniae

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16
Q

What is treatment for SBP?

A

Emergent antibiotics and hospitalization – risk of rapid progression to shock.

1) Provide albumin
2) Increased paracentesis
3) Prophylactic antibiotics

17
Q

What is the 1 year prognosis of SBP with out transplant?

A

50%

18
Q

What is the mechanism of hepatic encephalopathy?

A

conversion of ammonia to glutamine that is toxic to the brain (neurotransmission and astrocyte swelling)

19
Q

What is a protective mechanism against hyperammonmia?

A

Chronicity of liver disease will protect from hyperammonemia via extrahepatic mechanisms of ammonia

20
Q

What are some reasons that a chronic patient would develop hepatic encephalopathy ?

A

Dehydration, GI bleed, infection, TIPS

** look for infection**

21
Q

What is the treatment for hepatic encephalopathy?

A

Intubation for airway protection

Reversal of infection/precipitating factor

Elimination of nitrogenous sources

22
Q

What are some ways to remove excess nitrogen sources in hyperammonia

A

Lactulose, Rifaximin, Metronidazole

23
Q

What are some pulmonary risks due to cirrhosis?

A

Portopulmonary Hypertension, Hepatic Hydrothroax, hepatopulmonary syndrome, and restrictive lung because of ascites

24
Q

What is hepatopulmonary syndrome?

A

Hypoxemia due to diffusion impairment from alveoli to vasculature due to pathologic pulmonary dilation

25
Q

How does hepatic disease cause vasodilation in the pulmonary system?

A

Vasodilators will emanate from hepatic venous drainage into the IVC

26
Q

What are symptoms of HPS?

(Hepatic pulmonary syndrome)

A

Platypnea (dyspnea when upright)
Orthodeoxia (desaturation when upright)

due to west zone 3 predominance of vascular dilation

27
Q

How is HPS (Hepatic pulmonary syndrome) diagnosed?

A

Late bubbles in a TTE because there is dilation and takes a long time to get through + low DLCO

28
Q

How is HPS (Hepatic pulmonary syndrome) treated?

A

Liver transplant will fully reverse the hypoxemia

O2 will override the diffusion limitation

29
Q

What is the pathophys of portopulmonary HTN?

A

Vascular injury and inflammation mediated by serum factors and abnormal sheer stress due to hyper-dynamic flow

30
Q

What is the mPAP nrange to qualify for liver transplant?

A

25-35 mmHg

Not a good candidate past 35 mmHg

31
Q

What is the treatment of portopulmonary HTN?

A

Dobutamine, milrinone, iv epoprostenol (pulmonary dilation)

Liver transplant in which reversal is limited

32
Q

Results of liver transplant between portopulmonary hypertension vs hepatic pulmonary syndrome

A

LT will reverse HPS

LT may reverse to some degree PPHTN

33
Q

What is hepatic hydrothorax?

A

Transudative pleural effusion due to translocation of ascites

34
Q

What is a feared complication of hepatic hydrothorax?

A

Spontaneous bacterial empyema

35
Q

What is the treatment of hepatic hydrothroax?

A

Maximize diuretic therapy if renal function can handle

Serial thoracentesis

Gravity drainage via a small bore

TIPS for refractory hydrothorax

36
Q

What is hepatorenal syndrome?

A

Function renal damage in the presence of decompensated cirrhosis

37
Q

What is the treatment of HRS?

A

splanchnic vasoconstrictors and albumin, norepinephrine, dialysis and liver transplant

38
Q

What are some metabolic abnormalities experienced with those with chronic liver disease?

A

Anion gap metabolic acidosis, rapid onset of severe lactic acidosis in the setting of shock

Hypoglycemia

Hyponatremia

39
Q

How are infections handled in those with chronic liver disease?

A

Decompensated host is immunocompromised and requires rapid and intense treatment of any bacteria or fungal infection

GI Module (6 decks)

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