Syndromes of Cirrhosis Flashcards
What does cirrhosis encompass?
Disruption of vasculature, generation of abnormal signalling, loss of function
Where are the four portocaval anastomoses?
Oesophageal and gastric venous plexus
Umbilical vein from left portal vein to epigastric venous system
Retroperitoneal collateral vessels
Hemorrhoidal plexus
What can happen to the portocaval anastomoses in portal hypertension?
Become engorged, dilated or varicosed and rupture
What is portal hypertension?
Portal vein pressure above 5-8mmHg
Portal vein-hepatic vein pressure gradient greater than 5mHg
What are the two main drivers for portal hypertension?
Increased resistance to portal flow
Increase portal venous inflow
What are pre hepatic causes of portal hypertension?
Blockage of the portal vein before the liver
Due to portal vein thrombosis or occlusion secondary to congenital portal venous abnormalities
What are intrahepatic causes of portal hypertension?
Due to distortion of the liver architecture
Presinusoidal = schistosomiasis, non-cirrhotic PH
Postsinusoidal = cirrhosis, alcoholic hepatitis, congenital hepatic fibrosis
What are the post hepatic causes portal hypertension?
Blockages of the venous outflow from the liver
Budd Chiari syndrome
Veno-occlusive disease
What factors contribute to hepatic carcinogenesis?
Recurrent hepatocyte death -> regeneration -> cellular hyperplasia -> mitogenic environment
Inflammation -> degranulation cell cycle control -> DNA damage -> mutagenic environment
What re the three most common causes of cirrhosis?
Alcohol
Hepatitis C
NASH (NAFLD)
What are the pathological features of compensated cirrhosis?
Clinically normal
Incidental finding
Lab test or imaging abnormalities
Portal hypertension may be present
What are the pathological features of decompensated cirrhosis?
Acute on chronic liver failure =
Infection, insult, SIRS
End stage liver disease =
Insufficient hepatocytes, ran out of liver
What are the signs of compensated cirrhosis?
NONE Spider naevi Palmer erythema Finger clubbing Gynaecomastia Hepatomegaly (more likely to shrink) Splenomegaly
What are the signs of decompensated cirrhosis?
As decompensated, plus Jaundice Ascites Encephalopathy Bruising
What are the four main complications of cirrhosis?
Ascites
Encephalopathy
Variceal Bleeding
Liver Failure
What are the general principles for treatment of decompensated cirrhosis?
Remove/treat underling cause
Look for and treat infection
Normalise physiology - particularly NaCl retention
What are the nutritional considerations for decompensated cirrhosis?
Low threshold for gluconeogenesis and muscle catabolism
Need 35-40kcal/kg
Small frequent meals and snacks encouraged
Beware of overnight fasting
Reduce dietary NaCl
What are the vitamin and mineral requirements for decompensated cirrhosis?
Vit B supplementation Thiamine mandatory - Excess alcohol intake
Calcium and Vitamin D - Osteoporosis and osteomalacia
Monitor fat soluble vitamins and supplement if needed - PSC and PBC
Why does ascites happen in cirrhosis?
Retention of sodium and water
Portal hypertension causes a hydrostatic gradient which forces fluid into peritoneal cavity
What is the main aim in treatment of ascites?
Improve underlying liver disease
What is the role of looking for and treating infection in the management of ascites?
Patients are at risk of spontaneous bacterial peritonitis
What are the general principles of drug therapy in the management of ascites?
Diuretics - spironolactone first Avoid NSAIDs and other sodium retaining drugs
Monitor sodium levels due to other medications
What is the role of dietary advice in the management of ascites?
No added sodium diet
Reduce salt intake, maintain nutrition
If diuretics have not worked in reducing ascitic fluid, what may be considered next?
Paracentesis
Provides rapid relief
Risk of infection, encephalopathy and hypovolaemia
If diuretics and paracentesis are not suitably controlling symptoms, what may be considered next?
TIPS (transjugular intrahepatic portosystemic shunt)
Used for resistant ascites
Most often cures ascites, or gives ascites controlled with diuretics
What may have to be considered if ascites does not improve despite all other interventions, or SBP becomes a severe complication?
Liver transplantation
What is spontaneous bacterial peritonitis?
Translocated bacterial infection of ascites
What is the prognosis of spontaneous bacterial peritonitis?
Poor prognostic marker
How is spontaneous bacterial peritonitis diagnosed?
Not obvious
Do a tap in all ascites and cell count
Neutrophil >250 cells/mm3
What is the treatment for spontaneous bacterial peritonitis?
Urgent
Antibiotics and alba
Vascular isntability-terlipressin
Maintain renal perfusion
What is hepatic encephalopathy?
Reversible mental confusion which accompanies cirrhosis due to a build up of toxins
How is hepatic encephalopathy diagnosed?
Flap confusion
Any neurology
Alcohol withdrawal
What is the treatment for hepatic encephalopathy?
Look for and treat cause
Lactulose to clear gut/reduce transit time (rifaxamin)
Maintain nutritional status with small, frequent meals and bedtime CHO
Consider transplantation if spontaneous
What is the pathophysiology of variceal bleeding?
Increased hepatic resistance + portal blood flow
Increased vatical wall tension
Wall tension gets too high, varies pop
What is the progression of variceal bleeding?
1/3 of varies bleed 40-60% stop 70-80% rebleed Decompensation Liver failure Death
What are the primary prophylactic measures to prevent variceal bleeding?
Beta blockers (must be nonselective, so propranolol or carvideolol) Variceal ligation Regular endoscopy
What is the pathway for acute variceal bleeding?
Resuscitation
Vit K, FFP and platelet transfusion to correct clotting abnormalities
Start IV terlipressin
Endoscopic therapy
If uncontrolled, Sengstaken-Blakemore tube (ballon tamponade)
What are the two types of endoscopic therapy for variceal bleeding?
Sclerotherapy
Variceal Ligation
What are the pros/cons to sclerotherapy for variceal bleeding?
Effective and longterm Intra-variceal Free hand and flexible Sclero ulcers Complications
What are the pros to variceal ligation for variceal bleeding?
aka Banding
Quicker eradication
Lower morbidity
As effective
What are the pros/cons to balloon tamponade for treatment of variceal bleeding?
80-90% success
Risks of aspiration and perforation, usually fatal
Gastric balloon only
Used for uncontrolled bleeding varies
What are the pros/cons to TIPS for treatment for variceal bleeding?
Effective
Low mortality
Anyone, anytime
Encephalopathy
Blockage
What is the secondary prophylaxis for variceal bleeding?
Variceal band ligation
Beta-blockers
When might liver transplantation be considered in cirrhosis?
Event based = Resistant ascites, SBP, variceal bleed
Liver function based = Bilirubin, albumin, prothrombin time
QoL based = itch, lethargy, spontaneous encephalopathy
What UKELD score must a patient have to be listed for elective liver transplant and why?
49 (unless they have a variant syndrome or HCC)
Equals 9% 1 year mortality, which is the same as the 1 year mortality for elective liver transplant (i.e. more likely to die if they don’t have the surgery)
