SM_158b: Complications of Cirrhosis Flashcards
Cirrhosis involves ____, ____, and ____
Cirrhosis involves fibro-nodularity, synthetic dysfunction, and portal hypertension
- Prognosis worse for decompensated than compensated
Cirrhosis pathophysiology involves ____ often secondary to ____, ____, or ____
Cirrhosis pathophysiology involves inflammation often secondary to alcohol, non-alcoholic fatty liver disease, or HCV
Portal hypertension is ____
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
Symptoms of cirrhosis and portal hypertension are ____, ____, and ____
Symptoms of cirrhosis and portal hypertension are cognitive errors / slowness, abdominal fullness / leg swelling / weight gain, and fatigue
Ascites is ____ that presents with ____
Ascites is increased peritoneal fluid that presents with increased abdominal fullness and early satiation
- Exam: distended abdomen, shifting dullness
Describe pathophysiology of ascites
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)
Ascites treatments include ____, ____, ____, and ____
Ascites treatments include low salt diet, diuretics, paracentesis, and TIPS
Spontaneous bacterial peritonitis is ____
Spontaneous bacterial peritonitis is infected ascites
- Asymptomatic or abdominal pain
- Exam: may have abdominal pain or guarding
- Paracentesis: SBP ≥ 250 neutrophils/mm3
Describe pathophysiology of spontaneous bacterial peritonitis
Spontaneous bacterial peritonitis pathophysiology
- Bacteria (enteric)
- Lymphatics, across the intestinal wall
- Ascites
(more ascites, malnutrition -> decreased [opsonins]
Spontaneous bacterial peritonities treatment is ____
Spontaneous bacterial peritonities treatment is antibiotics with Gram +/- coverage
Hepatic hydrothorax is ____
Hepatic hydrothorax is increased pleural fluid
- Symptoms: dyspnea
- Exam: diminished breath sounds
- Labs: hypoxemia
- CXR: decreased lung capacity
- Thoracentesis: portal hypertension etiology, infections, malignancy
Describe pathophysiology of hepatic hydrothorax
Hepatic hydrothorax pathophysiology
- Pulmonary HTN -> ascites
- Intrathoracic pressure draws fluid through disaphragm rents
Hepatic hydrothorax treatment is ____, ____, ____, ____, and ____
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)
Hepatopulmonary syndrome is ____
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
Dyspnea (platypnea) and spider angiomata are indicative of _____
Dyspnea (platypnea) and spider angiomata are indicative of hepatopulmonary syndrome
Describe pathophysiology of hepatopulmonary syndrome
Hepatopulmonary syndrome pathophysiology
- Portal hypertension
- Increased vasodilators and angiogenesis
- Vascular shunts
- Oxygen mismatch
Mild hepatopulmonary syndrome is treated with ____, while severe hepatopulmonary syndrome is treated with ____
Mild hepatopulmonary syndrome is treated with oxygen supplementation, while severe hepatopulmonary syndrome is treated with organ transplantation
Portopulmonary hypertension is ____
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
Describe pathophysiology of portopulmonary hypertension
Portopulmonary hypertension pathophysiology
- Portal hypertension
- Induces vasoconstrictors in lung
- Increased vasoconstriction, arterial thickening, fibrosis, and thrombosis
- Increased pulmonary artery pressures
- Increased right heart failure
Patients with severe portopulmonary hypertension ____ transplant
Patients with severe portopulmonary hypertension CANNOT have transplant
Hepatorenal syndrome is ____
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
Describe pathophysiology of hepatorenal syndrome
Hepatorenal syndrome pathophysiology
- Portal hypertension
- Splanchnic dilation
- Renal vasoconstriction and increased RAA
- Increased compensatory cardiac output
- Massively increased portal hypertension
- Renal ischemia
- Renal failure with anuria
- Uremia
Hepatorenal syndrome treatments include ____, ____, and ____
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
Esophageal varices are ____
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)
Describe pathophysiology of esophageal varices
Esophageal varices pathophysiology
- Portal hypertension
- Reversal of flow (hepatofugal) into esophagus veins
- Engorged veins
- Increased bleeding risk
Bleeding esophageal varices treatments are ____, ____, ____, ____, and ____
Bleeding esophageal varices treatments are volume resuscitation, coagulopathy, medications (acid suppression, infectious prophylaxis, portal hypertension control), EGD, and TIPS
Hepatic encephalopathy is ____
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
Describe the pathophysiology of hepatic encephalopathy
Hepatic encephalopathy
- NH3 flux: intestines (+ bacteria), kidney, muscle
- Cirrhosis: impaired NH2 detoxification, portal hypertension shunting
- Precipitants: constipation (main), GI bleeding, infection
- Increased NH3
- Brain cell swelling, abnormal neural signaling
Hepatic encephalopathy treatment includes ____ and ____
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
Hepatocellular carcinoma is ____
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
Hepatocellular carcinoma occurs due to ____ and ____ most often in people with ____
Hepatocellular carcinoma occurs due to chronic liver inflammation and regeneration most often in people in cirrhosis
- HBV (age, ethnicity)
- PBC (male)
Hepatocellular carcinoma is ____, ____, ____, and ____
Hepatocellular carcinoma is liver-direct therapies, resection, transplantation, chemotherapy
