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GI > SM_158b: Complications of Cirrhosis > Flashcards

SM_158b: Complications of Cirrhosis Flashcards

1
Q

Cirrhosis involves ____, ____, and ____

A

Cirrhosis involves fibro-nodularity, synthetic dysfunction, and portal hypertension

  • Prognosis worse for decompensated than compensated
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2
Q

Cirrhosis pathophysiology involves ____ often secondary to ____, ____, or ____

A

Cirrhosis pathophysiology involves inflammation often secondary to alcohol, non-alcoholic fatty liver disease, or HCV

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3
Q

Portal hypertension is ____

A

Portal hypertension is increased portal vein pressure

  • Portal vein: superior mesenteric vein + splenic vein
  • Subtypes: intrahepatic (alcohol, HCV), posthepatic (Budd-Chiari syndrome), or prehepatic (vein thrombosis, schistosomiasis)
  • Pathophysiology: pressure due to fibrosis (fixed), inflammation, and blood volume
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4
Q

Symptoms of cirrhosis and portal hypertension are ____, ____, and ____

A

Symptoms of cirrhosis and portal hypertension are cognitive errors / slowness, abdominal fullness / leg swelling / weight gain, and fatigue

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5
Q

Ascites is ____ that presents with ____

A

Ascites is increased peritoneal fluid that presents with increased abdominal fullness and early satiation

  • Exam: distended abdomen, shifting dullness
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6
Q

Describe pathophysiology of ascites

A

Ascites pathophysiology

  • Increased portal hypertension -> increased nitric oxide and vasodilation -> decreased renal perfusion
  • Increased AA, SNS, and ADH -> fluid retention -> increased portal hypertension
  • Liver filters fluid into peritoneum (ascites)
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7
Q

Ascites treatments include ____, ____, ____, and ____

A

Ascites treatments include low salt diet, diuretics, paracentesis, and TIPS

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8
Q

Spontaneous bacterial peritonitis is ____

A

Spontaneous bacterial peritonitis is infected ascites

  • Asymptomatic or abdominal pain
  • Exam: may have abdominal pain or guarding
  • Paracentesis: SBP ≥ 250 neutrophils/mm3
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9
Q

Describe pathophysiology of spontaneous bacterial peritonitis

A

Spontaneous bacterial peritonitis pathophysiology

  1. Bacteria (enteric)
  2. Lymphatics, across the intestinal wall
  3. Ascites

(more ascites, malnutrition -> decreased [opsonins]

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10
Q

Spontaneous bacterial peritonities treatment is ____

A

Spontaneous bacterial peritonities treatment is antibiotics with Gram +/- coverage

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11
Q

Hepatic hydrothorax is ____

A

Hepatic hydrothorax is increased pleural fluid

  • Symptoms: dyspnea
  • Exam: diminished breath sounds
  • Labs: hypoxemia
  • CXR: decreased lung capacity
  • Thoracentesis: portal hypertension etiology, infections, malignancy
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12
Q

Describe pathophysiology of hepatic hydrothorax

A

Hepatic hydrothorax pathophysiology

  1. Pulmonary HTN -> ascites
  2. Intrathoracic pressure draws fluid through disaphragm rents
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13
Q

Hepatic hydrothorax treatment is ____, ____, ____, ____, and ____

A

Hepatic hydrothorax treatment is low salt diet, diuretics, thoracentesis, TIPS, pleurodesis

  • TIPS mechanism: liver shunt -> decreased intrahepatic resistance -> decreased portal hypertension
  • Pleurodesis mechanism: chemical pleural bonding (not effective)
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14
Q

Hepatopulmonary syndrome is ____

A

Hepatopulmonary syndrome is portal hypertension induced pulmonary shunting

  • Symptoms: dyspnea (platypnea: while sitting up)
  • Exam: spider angiomata
  • Labs: ABG shows low PaO2 (+ orthodeoxia: hypoxemia on pulse oximetry)
  • Echo (cardiac ultrasound): positive bubble study
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15
Q

Dyspnea (platypnea) and spider angiomata are indicative of _____

A

Dyspnea (platypnea) and spider angiomata are indicative of hepatopulmonary syndrome

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16
Q

Describe pathophysiology of hepatopulmonary syndrome

A

Hepatopulmonary syndrome pathophysiology

  1. Portal hypertension
  2. Increased vasodilators and angiogenesis
  3. Vascular shunts
  4. Oxygen mismatch
17
Q

Mild hepatopulmonary syndrome is treated with ____, while severe hepatopulmonary syndrome is treated with ____

A

Mild hepatopulmonary syndrome is treated with oxygen supplementation, while severe hepatopulmonary syndrome is treated with organ transplantation

18
Q

Portopulmonary hypertension is ____

A

Portopulmonary hypertension is portal hypertension induced pulmonary hypertension

  • Symptoms: dyspnea
  • Exam: digital clubbing
  • Labs: hypoxemia on pulse oxymetry
  • Echo (cardiac US): increased pulmonary artery pressure
  • Right heart catheterization
19
Q

Describe pathophysiology of portopulmonary hypertension

A

Portopulmonary hypertension pathophysiology

  1. Portal hypertension
  2. Induces vasoconstrictors in lung
  3. Increased vasoconstriction, arterial thickening, fibrosis, and thrombosis
  4. Increased pulmonary artery pressures
  5. Increased right heart failure
20
Q

Patients with severe portopulmonary hypertension ____ transplant

A

Patients with severe portopulmonary hypertension CANNOT have transplant

21
Q

Hepatorenal syndrome is ____

A

Hepatorenal syndrome is decreased renal perfusion in severe portal hypertension leading to AKI

  • Symptoms: increased wieight, dyspnea
  • Exam: cirrhotic patient, increased ascites, increased edema
  • Labs: increased Cr, renal studies look prerenal with oliguria
22
Q

Describe pathophysiology of hepatorenal syndrome

A

Hepatorenal syndrome pathophysiology

  1. Portal hypertension
  2. Splanchnic dilation
  3. Renal vasoconstriction and increased RAA
  4. Increased compensatory cardiac output
  5. Massively increased portal hypertension
  6. Renal ischemia
  7. Renal failure with anuria
  8. Uremia
23
Q

Hepatorenal syndrome treatments include ____, ____, and ____

A

Hepatorenal syndrome treatments include medications, renal replacement therapies, and liver ± kidney transplantation

  • Medications: vasoconstrictor (alpha agonist: midrodine), vasodilator inhibitor / vasconstrictor (glucagon inhibitor: octreotide, alpha/beta agonist: epinephrine), and oncotic (pleitropic: IV albumin) support
  • Renal replacement therapies: hemodialysis
  • Liver ± kidney transplant: kidney function sometimes improves post-liver transplant
24
Q

Esophageal varices are ____

A

Esophageal varices are portal hypertension-induced enlarged or new veins

  • Symptoms: asymptomatic to hematemesis
  • Exam (if bleeding): tachycardia, hypotension
  • Labs (if bleeding): decreased hemoglobin, increased BUN
  • EGD: direct visualization (definitive)
25
Q

Describe pathophysiology of esophageal varices

A

Esophageal varices pathophysiology

  1. Portal hypertension
  2. Reversal of flow (hepatofugal) into esophagus veins
  3. Engorged veins
  4. Increased bleeding risk
26
Q

Bleeding esophageal varices treatments are ____, ____, ____, ____, and ____

A

Bleeding esophageal varices treatments are volume resuscitation, coagulopathy, medications (acid suppression, infectious prophylaxis, portal hypertension control), EGD, and TIPS

27
Q

Hepatic encephalopathy is ____

A

Hepatic encephalopathy is altered mentation in cirrhosis due to engoenous toxin build up

  • Symptoms: altered mentation, report of constipation
  • Exam: memory tests, asterixis
  • Labs: rule out toxins, infections, electrolyte issues - do not check ammonia
  • CT brain: exclude other causes
28
Q

Describe the pathophysiology of hepatic encephalopathy

A

Hepatic encephalopathy

  1. NH3 flux: intestines (+ bacteria), kidney, muscle
  2. Cirrhosis: impaired NH2 detoxification, portal hypertension shunting
  3. Precipitants: constipation (main), GI bleeding, infection
  4. Increased NH3
  5. Brain cell swelling, abnormal neural signaling
29
Q

Hepatic encephalopathy treatment includes ____ and ____

A

Hepatic encephalopathy treatment includes ammonia control and treatment of precipitants

  • Ammonia control: NH3 to NH4+ converter (lactulose), antibiotic (non-absorbable: rifaximin)
  • Constipation: as above
  • Bleeding: EGD
  • Sepsis: antibiotics
  • Volume depletion: IV fluids, hold diuretics
30
Q

Hepatocellular carcinoma is ____

A

Hepatocellular carcinoma is malignant hepatocytes

  • Symptoms: asymptomatic (mostly)
  • Exam: none (in early stage), palpable (late stage)
  • Labs: alpha fetal protein: inconsistent production ± utility
  • Imaging: CT/MRI contrast
  • Biopsy: uncommon for diagnosis ± utility
31
Q

Hepatocellular carcinoma occurs due to ____ and ____ most often in people with ____

A

Hepatocellular carcinoma occurs due to chronic liver inflammation and regeneration most often in people in cirrhosis

  • HBV (age, ethnicity)
  • PBC (male)
32
Q

Hepatocellular carcinoma is ____, ____, ____, and ____

A

Hepatocellular carcinoma is liver-direct therapies, resection, transplantation, chemotherapy

GI (40 decks)

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