Syndromes of Cirrhosis Flashcards
which structures does the portal vein drain?
spleen oesophagus stomach pancreas small and large intestine
pressure is higher in the hepatic artery then hepatic vein and portal vein, true or false?
true
flow is greater in the portal vein than the hepatic vein, true or false?
true
describe the process of hepatic blood flow
oxygenated blood from hepatic artery + nutrient rich deoxygenated blood from hepatic vein > liver sinusoids > central vein > hepatic vein > IVC > right atrium
whiat vascular sites may become engorged, dilated, varicosed or ruptured?
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
what defines portal hypertension?
portal vein pressure >5-8
Portal vein/hepatic vein pressure gradient > 5
what 2 factors contribute to portal hypertension?
increased resistance to portal flow (R)
increased portal venous flow (Q)
change in pressure = QXR
what are the 2 types of portal hypertension?
prehepatic - blockage of vein before liver
intrahepatic - distortion of liver architechture (pre/post sinusoidal)
name 3 hepatic carcinogenesis pathways
recurrent hepatocyte death
inflammation
aetiology - HBV DNA integration
what are the most common causes of cirrhosis?
alcohol
HCV
NASH/NAFLD
how does compensated cirrhosis present?
clinically normal, incidental finding
lab test/imaging abnormalities
portal hypertension may be present
how does decompensated cirrhosis present?
liver failure acute on chronic - infection - insult - SIRS end stage liver disease
what are the clinical signs of compensated cirrhosis?
spider naevi palmar erythema clubbing gynaecomastia hepatomegaly splenomegaly sometimes none
what are the clinical signs of decompensated cirrhosis?
jaundice
ascites
encephalopathy
bruising
what are the possible complications of cirrhosis?
ascites
encephalopathy
variceal bleeding
liver failure
how is decompensated cirrhosis treated?
remove/treat cause
look for and treat infection
avoid NaCl retention
what nutrition is recommended for liver disease?
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
how does cirrhosis lead to ascites?
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
how is ascites treated?
treat liver disease/infection NO NSAIDs reduce salt spironolactone (diuretics) paracentesis TIPSS transplant
how is ascites treated?
treat liver disease/infection NO NSAIDs reduce salt spironolactone (diuretics) paracentesis TIPSS transplant
what is post liver transplant survival?
85% 1 year survival
after 1 year basically the same as normal for age
what is UKELD score?
> 49 = suitable for liver transplant
predicts probability of death while on waiting list
how are diuretics used in ascites?
aldosterone antagonist (spironolactone) in new ascites spironolactone and loop diuretic stepwise in recurrent ascites Monitor Us&Es after does change or paracentesis
what are the benefits and risks of paracentesis?
rapid relief
risk of infection, encephalopathy and hypovolaemia
what is TIPPS?
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
what is spontaneous bacterial peritonitis (SBP)?
translocated bacterial infection of ascites
bad prognosis
Neutrophils >250 in ascites aspirate
how is SBP treated?
antibiotics and alba
terlipressin
maintain renal perfusion
what is encephalopathy?
confusion due to increased blood ammonia
can give hand flap
liver failure and portal-systemic shunts can cause it
how does increased blood ammonia cause encephalopathy?
increased ammonia may induce disturbance in astrocytes which might impair mitochondria and the glutamate - glutamine trafficking between neurons and astrocytes.
how is encephalopathy treated?
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
what is variceal bleeding mortality?
20% Childs A = 20% Childs B = 30-80% Childs C = 85% 1/3 of varices bleed 40-60% stop 70-80% rebleed
how can bleeding be prevented if varices are found?
B-blockers (propanalol and carvidelol)
Variceal ligation
what endoscopic therapies are there for oesophageal varices bleed?
sclerotherapy
Variceal ligation (banding)
- just as effective, quicker and less complications
what is balloon tamponade?
tube inserted through mouth and balloon inflated in stomach
complication risks so only use in emergency
