Portal Hypertension Flashcards by Sarah shaver

Where is the site of increased resistance in cirrhosis?

Sinusoidal

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How are pressures in the portal system measured?

HVPG: hepatic venous pressure gradient

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What is the formula for HVPG?

HVPG= WHVP-FHVP

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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

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What are the 4 locations of varices?

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

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What is the preventative treatment for varices?

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

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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)

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What are necessary steps to developing ascites secondary to cirrhosis ?

Sinusoidal Hypertension and HVPG > 12 mmHg

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What is the mechanism of ascites development?

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

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How is ascites defined?

Serum albumin to ascites gradient is >1.1 –> PHTN

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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

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What is the treatment of ascites?

Diuretics 
Sodium restriction 
Therapeutic paracentesis 
TIPS 
Transplant

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What is Spontaneous bacterial peritonitis?

Peritoneal infection of ascites in the absence of a perforated viscus

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How is the diagnosis of SBP made?

> 250 ascitic PMN’s per mm3

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What are the common infectious agents of SBP?

Gram neg or gram positive.

E. Coli, Klebsiella pneumoniae, and streptococcal pneumoniae

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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