Syndromes of cirrhosis Flashcards
what does cirrhosis look like?
= fibrous rings separated by degenerative nodules hepatocytes
what makes up the portal vein?
- superior mesenteric
- splenic vein
- gastric
- part from inferior mesenteric
what does portal vein carry outflow from?
- spleen
- oesophagus
- stomach
- pancreas
- small and large intestine
pressure in hepatic vein is usually what?
low
what are 4 collateral pathways?
- Esophageal and gastric venous plexus
- umbilical vein from the left portal vein to the epigastric venous system
- retroperitoneal collateral vessels
- the hemorrhoidal venous plexus
what could happen to anastomoses when there is portal hypertension?
- engorged, dilated or varicosed = rupture
what is portal hypertension?
= portal vein pressure above normal rates of 5-8mmHg
= portal vein-hepatic vein pressure gradient greater than 5mmHg
what does portal hypertension represent?
= an increase in hydrostatic pressure within portal vein or its tributaries
why does portal hypertension occur?
- increased resistance to portal flow
- increased portal venous inflow
how can you classify the causes of portal hypertension?
1) pre-hepatic
= blockage of portal vein before liver due to portal vein thrombosis or occlusion secondary to congenital portal venous abnormality
2) intra-hepatic
= due to distortion of liver architecture either;
- per sinusoidal
- post sinusoidal
what are the commonest cause of cirrhosis?
- alcohol
- hepatits C virus
- NASH (NAFLD)
what are 2 types of clinical cirrhosis?
1) compensated
2) decompensated cirrhosis
describe compensated cirrhosis?
- clinical normal
- incidental finding
- lab test or imaging abnormality
- portal hypertension may be present
describe decompensated cirrshosis?
= liver failure - acute or chronic = infection = insult = SIRS
- end stage liver disease
= insufficiency hepatocytes
= run out of liver
what are clinical signs of compensated cirrhosis?
spider naevi
palmar erythema
clubbing
hepatomegaly
spleenomegaly
gynaecomastia
what are clinical signs of decompensated cirrhosis?
jaundice
ascites
encephalopathy
bruising
what are 4 complications of cirrhosis?
- ascites
- encephalopathy
- variceal bleeding
- liver failure
what are the general principles of treatment of decompensated cirrhosis?
- remove or treat underlying cause
- look for and treat infection
- physiology isn normal
= avid NaCl retention - switch to gluconeogensis and lipolysis and catabolism
why is small frequent meals and snacks recommended for in cirrhosis?
= reduces fasting gluconeogensis and muscle catabolism
why does ascites occur in cirrhosis?
- portal hypertension
- hepatocellular dysfunction
- increased production fo vasodilators
- splanchnic arteriolar vasodilation
- activation of arterial baroreceptors
- activation of SNS RAAS AVP ET
- renal vasoconstriction, sodium and water retention
how do you diagnose ascites?
= ultrasound
= shifting dullness
how do you treat ascites?
- improve underlying liver disease
- look for and treat infection = SBP
- drugs NO NSAIDS = if IV think of sodium load
- reduce salt intake, maintain nutrition
- diuretics = spironolactone first
- paracentesis
- TIPSS
- transplantation
what diuretic should be used for ascites?
= spironlactone better than amiloride
what are 4 things that ascites paracentesis does?
- rapid relief
- risk of infection
- encephalopathy
- hypovolaemia
what is spontaneous bacterial peritonitis, SBP?
= translocated bacterial infection fo ascites
how do you diagnose SBP?
= differential
= do a tap in all ascites and cell count
- neutrophil count > 250cells/mm3
how do you treat SBP?
- Urgent
- Antibiotics and Alba
- Vascular instability-terlipressin
- Maintain renal perfusion
- HRS development very poor prognosis
what causes encephalopathy?
- microglial inflammation
- ammonia glutamate/glutamine shuttle
how do you diagnose ecephalopathy?
- flap confusion
- any neurology
- alcohol withdrawal
how do you treat encephalopathy?
- Look for cause-infection, metabolic, drugs, liver failure
- Treat it
- Lactulose to clear gut/ reduce transit time
= Rifaxamin - Maintain nutritional status with small, frequent meal/snack pattern and bedtime CHO
- If spontaneous consider transplantation
what is primary prophylaxis of varices oesophageal?
Beta blockers
- propanolol
- carvideolol
= non-selective
Varicela ligation
how do you deal with acute variceal bleeding?
- resuscitation
- pharmacological
- timing of therapy
- failed therapy
= TIPSS
= transection/shunt surgery
describe endoscopic herpay?
= sclerotherapy
- effective & long-term
- intra-variceal
- freehand & flexible
- sclero-ulcers
= variceal ligation
- banding
- quicker eradication
- lower morbidity
when is balloon tamponade used?
= variceal bleeding
gastric balloon only
what are risks of balloon tamponade?
- complication rate
- aspiration
- perforation usually fatal
what is TIPSSS?
trans-jugular intra-hepatic porto-systemic shunts
when do you use TIPSSS?
when beta blockers and variceal ligation doesn’t work
