Syndromes of Cirrhosis Flashcards by Rachel Agnew

What does cirrhosis encompass?

Disruption of vasculature, generation of abnormal signalling, loss of function

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What can happen to the portocaval anastomoses in portal hypertension?

Become engorged, dilated or varicosed and rupture

How well did you know this?

Not at all

Perfectly

What is portal hypertension?

Portal vein pressure above 5-8mmHg

Portal vein-hepatic vein pressure gradient greater than 5mHg

How well did you know this?

Not at all

Perfectly

What are the two main drivers for portal hypertension?

Increased resistance to portal flow

Increase portal venous inflow

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What are the post hepatic causes portal hypertension?

Blockages of the venous outflow from the liver
Budd Chiari syndrome
Veno-occlusive disease

How well did you know this?

Not at all

Perfectly

What factors contribute to hepatic carcinogenesis?

Recurrent hepatocyte death -> regeneration -> cellular hyperplasia -> mitogenic environment
Inflammation -> degranulation cell cycle control -> DNA damage -> mutagenic environment

How well did you know this?

Not at all

Perfectly

What re the three most common causes of cirrhosis?

Alcohol
Hepatitis C
NASH (NAFLD)

How well did you know this?

Not at all

Perfectly

What are the pathological features of compensated cirrhosis?

Clinically normal
Incidental finding
Lab test or imaging abnormalities
Portal hypertension may be present

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What are the signs of compensated cirrhosis?

NONE
Spider naevi 
Palmer erythema 
Finger clubbing 
Gynaecomastia 
Hepatomegaly (more likely to shrink)
Splenomegaly

How well did you know this?

Not at all

Perfectly

What are the signs of decompensated cirrhosis?

As decompensated, plus 
Jaundice 
Ascites 
Encephalopathy 
Bruising

How well did you know this?

Not at all

Perfectly

What are the four main complications of cirrhosis?

Ascites
Encephalopathy
Variceal Bleeding
Liver Failure

How well did you know this?

Not at all

Perfectly

What are the general principles for treatment of decompensated cirrhosis?

Remove/treat underling cause
Look for and treat infection
Normalise physiology - particularly NaCl retention

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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)