Syndromes of Cirrhosis

Question 1

which structures does the portal vein drain?

Answer 1

spleen
oesophagus
stomach
pancreas
small and large intestine

Question 2

pressure is higher in the hepatic artery then hepatic vein and portal vein, true or false?

Answer 2

true

Question 3

flow is greater in the portal vein than the hepatic vein, true or false?

Answer 3

true

Question 4

describe the process of hepatic blood flow

Answer 4

oxygenated blood from hepatic artery + nutrient rich deoxygenated blood from hepatic vein > liver sinusoids > central vein > hepatic vein > IVC > right atrium

Question 5

whiat vascular sites may become engorged, dilated, varicosed or ruptured?

Answer 5

sites of portocaval anastomoses

• oesophageal and gastric venous plexus
• umbilical vein from left portal vein to epigastric venous system
• retroperitoneal collateral vessels
• haemorrhoidal venous plexus

Question 6

what defines portal hypertension?

Answer 6

portal vein pressure >5-8

Portal vein/hepatic vein pressure gradient > 5

Question 7

what 2 factors contribute to portal hypertension?

Answer 7

increased resistance to portal flow (R)
increased portal venous flow (Q)
change in pressure = QXR

Question 8

what are the 2 types of portal hypertension?

Answer 8

prehepatic - blockage of vein before liver

intrahepatic - distortion of liver architechture (pre/post sinusoidal)

Question 9

name 3 hepatic carcinogenesis pathways

Answer 9

recurrent hepatocyte death
inflammation
aetiology - HBV DNA integration

Question 10

what are the most common causes of cirrhosis?

Answer 10

alcohol
HCV
NASH/NAFLD

Question 11

how does compensated cirrhosis present?

Answer 11

clinically normal, incidental finding
lab test/imaging abnormalities
portal hypertension may be present

Question 12

how does decompensated cirrhosis present?

Answer 12

liver failure
acute on chronic 
- infection
- insult
- SIRS
end stage liver disease

Question 13

what are the clinical signs of compensated cirrhosis?

Answer 13

spider naevi
palmar erythema
clubbing
gynaecomastia
hepatomegaly
splenomegaly
sometimes none

Question 14

what are the clinical signs of decompensated cirrhosis?

Answer 14

jaundice
ascites
encephalopathy
bruising

Question 15

what are the possible complications of cirrhosis?

Answer 15

ascites
encephalopathy
variceal bleeding
liver failure

Question 16

how is decompensated cirrhosis treated?

Answer 16

remove/treat cause
look for and treat infection
avoid NaCl retention

Question 17

what nutrition is recommended for liver disease?

Answer 17

35-40kcal/kg
1.2-1.5g/kg protein
small frequent meals and snacks to reduce fasting gluconeogenesis and muscle catabolism
Vit B in alcoholism
Fat soluble vitamins in PSC and PBC
Calcium and Vit D in osteoporosis and osteomalacia

Question 18

how does cirrhosis lead to ascites?

Answer 18

cirrhosis > portal hypertension > portosystemic shunting > increased vasodilator production and vasoconstrictor resistance > splanchnic arteriolar vasodilation > activation of arterial baroreceptors > activates SNS, RAAS, AVP and ET > renal vasoconstriction, sodium and water retention

Question 19

how is ascites treated?

Answer 19

treat liver disease/infection
NO NSAIDs
reduce salt
spironolactone (diuretics)
paracentesis
TIPSS
transplant

Question 20

how is ascites treated?

Answer 20

treat liver disease/infection
NO NSAIDs
reduce salt
spironolactone (diuretics)
paracentesis
TIPSS
transplant

Question 21

what is post liver transplant survival?

Answer 21

85% 1 year survival

after 1 year basically the same as normal for age

Question 22

what is UKELD score?

Answer 22

> 49 = suitable for liver transplant

predicts probability of death while on waiting list

Question 23

how are diuretics used in ascites?

Answer 23

aldosterone antagonist (spironolactone) in new ascites 
spironolactone and loop diuretic stepwise in recurrent ascites
Monitor Us&Es after does change or paracentesis

Question 24

what are the benefits and risks of paracentesis?

Answer 24

rapid relief

risk of infection, encephalopathy and hypovolaemia

Question 25

what is TIPPS?

Answer 25

connects the portal vein to the hepatic vein in the liver. Stent placed to keep connection open and allow it to bring blood draining from the bowel back to the heart while avoiding the liver.
encephalopathy and blockage risks

Question 26

what is spontaneous bacterial peritonitis (SBP)?

Answer 26

translocated bacterial infection of ascites
bad prognosis
Neutrophils >250 in ascites aspirate

Question 27

how is SBP treated?

Answer 27

antibiotics and alba
terlipressin
maintain renal perfusion

Question 28

what is encephalopathy?

Answer 28

confusion due to increased blood ammonia
can give hand flap
liver failure and portal-systemic shunts can cause it

Question 29

how does increased blood ammonia cause encephalopathy?

Answer 29

increased ammonia may induce disturbance in astrocytes which might impair mitochondria and the glutamate - glutamine trafficking between neurons and astrocytes.

Question 30

how is encephalopathy treated?

Answer 30

treat cause
- infection
- metabolic
- drugs
- liver failure
lactulose to clear gut and reduce transit time
rifaxamin
maintain nutrition with small frequent meals and bedtime carbohydrate snack
consider transplant if spontaneous

Question 31

what is variceal bleeding mortality?

Answer 31

20%
Childs A = 20%
Childs B = 30-80%
Childs C = 85%
1/3 of varices bleed
40-60% stop
70-80% rebleed

Question 32

how can bleeding be prevented if varices are found?

Answer 32

B-blockers (propanalol and carvidelol)

Variceal ligation

Question 33

what endoscopic therapies are there for oesophageal varices bleed?

Answer 33

sclerotherapy
Variceal ligation (banding)
- just as effective, quicker and less complications

Question 34

what is balloon tamponade?

Answer 34

tube inserted through mouth and balloon inflated in stomach

complication risks so only use in emergency