The syndromes of Cirrhosis Flashcards
What is cirrhosis
Common final pathway
Fibrosis and regeneration in a continue from chronic liver disease
What does cirrhosis cause
dysfunction
disruption of vasculature
generation of abnormal signalling
What is the portal system
Superior mesenteric splenic vein gastric part of the inferior mesenteric =portal vein
Where does the portal vein carry outflow from
spleen oesophagus stomach pancreas small and large intestine
What is the pathway of blood through the liver
From hepatic artery and portal vein liver sinusoids central vein hepatic vein IVC right atrium,
What is portal hypertension
Portal vein pressure above the normal range of 5-8mm Hg
What does portal hypertension result from
Increased resistance to portal flow
Increased portal venous inflow
What is prehepatic portal hypertension
blockage of the portal vein before the liver due to thrombosis, occlusion or congenital abnormalities
Intrahepatic portal hypertension
Distortion of the liver architecture
What are the types of intrahepatic portal hypertension
Presinusiodal -non cirrhotic
postsinfusiodial -caused by cirrhosis, alcoholic hep, congenital hepatic fibrosis
What is compensated cirrhosis
Clinical normal
incidental finding
lab test or imaging abnormalities
portal hypertension may be present
Decompensated cirrhosis
Liver failure acute on chronic -infection -insult -SIRS End stage liver disease -insufficient hepatocytes -'run out of liver'
Signs of compensated cirrhosis
Spider navei Polar erythema clubbing gynaecomastia hepatomegaly spleenomegaly or none
Sings of decompensated cirrhosis
Jaundice
Ascites
Encephalopathy
Bruising
Complications of cirrhosis
Ascites
Encephalopathy
Variceal bleeding
Liver failure
General principles of decompensated cirrhosis treatment
Remove or treat underlying cause
Look for and treat infection
Avoid NaCl retention
Low threshold to switch to glycogenesis and lipolysis catabolism
Nutrition for those with cirrhosis
Small frequent meals and snack encouraged as this reduces fasting gluconeogenesis and muscle catabolism
Bit B supplements
Osteoporosis is common complication
fat soluble vitamin deficiency may occur- monitor vitamins
What causes Ascites
- Cirrhosis
- Portal hypertension
- Hepatocellular dysfunction and portosystemic shunting
- increased production of vasodilators
- splanchnic arteriolar vasodilation
- activation of arterial baroreceptors
- activation of SNS, RAAS, AVP, ET
- renal vasoconstriction
- sodium and water retention
How to treat ascites
Improve underlying liver disease Look for and treat infection Drugs- no NSAIDS, if IV think of sodium load Reduce salt intake, maintain nutrition Diuretics -spironolactone first Paracentisis TIPSS (trans-jugular intra hepatic porto systemic shunt) Transplantation
What diuretics to use in ascites
Aldosterone antagonism
Spiralactone is better than amiloride In recurrent ascites use spiralactone and a loop diuretic
Frequently monitor U&E
Pros and cons of ascites paracentesis
pro rapid relief con risk of infection encephalopathy hypovolaemia
What causes encephalopathy
theories
- microglial inflammation
- ammonia glutamate shuttle
How to diagnose encephalopathy
Flap
confuction
any neurology
dont confuse with alcohol withdrawal
Treatment for encephalopathy
Look for cause: -infection -metabolic drugs -liver failure Treat it Lactulose to clear gut/reduce transmit time maintain nutritional status if spontaneous consider transplantation
Endoscopic therapy for variceal bleeding
Sclerotherapy
- effecting & long term
- intra variceal
- free hand &flexible
- clero-ulcers
- complications
Variceal Ligation
- ‘banding’
- quicker eradication
- lower morbidity
- as effective
What is balloon tamponade
Put a tube down into stomach
inflate balloon to stop bleeding
only used when needed to save a life
Trans jugular inter hepatic systemic shine
effective low mortality anyone can get it any time BUT encephalopathy blockage
How do you decide if someone gets a liver transplant
Event based
-ascites-resistant or spontaneous bacterial peritonitis
-variceal bleeding
Liver function based
-bilirubin, albumin, prothrombin
quality of life based
-itch, lethargy, spontaneous encephalopathy
