UW revision cirrhosis 03-05 (2) Flashcards
Cirrhosis. Initial evaluation?
History taking: medications, social habits (alcohol, drugs use, high risk sexual activity), and family history (eg to exclude hemochromatosis).
Cirrhosis. Labs?
viral hepatitis serologies and iron studies
How to distinguish cirrhosis?
Paracenthesis + SAAG calculation
can distinguish between portal hypertensive and non-portal hypertensive causes
Cirrhosis assoc. with shrunken liver and splenomegaly (congestion from portal hypertension) BUT hepatomegaly can occasionally be seen in early cirrhosis due to ongoing inflammation.
.
Other portal hypertensive ascites causes?
constrictive pericarditis, right sided heart failure.
NONportal hypertensive ascites causes?
Nephrotic syndrome, peritoneal carcinomatosis
NONportal hypertensive ascites CP finding?
Jugular venous distension is expected (eg hepatojugular reflux)
portal hypertensive ascites CP finding absent?
NO HEPATOJUGULAR REFLUX
Nephrotic syndrome mechanisms?
Edema and ascites due to hypoalbuminemia.
NO INCREASED PRESSURE. Portal pressure is unaffected, therefore hepatosplenomegaly is not expected.
Ovarian cancer with peritoneal metastasis (ie carcinomatosis) causes ascites with what portal pressure?
ascites without portal hipertension.
THEREFORE no hepatosplenomegaly.
Evaluation of ascites scheme.
First step?
perform diagnostic paracentesis
Evaluation of ascites scheme.
perform diagnostic paracentesis –> next?
Calculate SAAB (serum albumin - ascites albumin)
Evaluation of ascites scheme.
perform diagnostic paracentesis –> calculate SAAB –> IF HIGH (>= 1,1) –> interpretation and causes? 4
ELEVATED PORTAL PRESSURE
Cirrhosis (most common)
HF
Portal vein thrombosis
Budd-Chiari syndrome
Evaluation of ascites scheme.
perform diagnostic paracentesis –> calculate SAAB –> IF LOW (< 1,1) –> interpretation? what 2 groups?
Portal pressure is not elevated.
Peritoneal inflammation OR very low serum albumin.
Evaluation of ascites scheme.
perform diagnostic paracentesis –> calculate SAAB –> IF LOW (< 1,1) –> Portal pressure is not elevated –>
Peritoneal inflammation. 3?
Peritoneal malignancy
Tuberculosis
Pancreatitis
Evaluation of ascites scheme.
perform diagnostic paracentesis –> calculate SAAB –> IF LOW (< 1,1) –> Portal pressure is not elevated –>
very low serum albumin. 1?
Nephrotic syndrome
3 groups of liver dysfunction that cirrhosis cause?
Synthetic
metabolic
excretory
3 groups of liver dysfunction that cirrhosis.
Synthetic. 3?
Production of clotting factors, cholesterol, proteins
3 groups of liver dysfunction that cirrhosis.
Metabolic. 2?
Metabolism of drugs and corticosteroids, including detoxification
3 groups of liver dysfunction that cirrhosis.
Excretory 1?
Bile excretion
what 2 CP due to hyperestrinism? general
spider angiomas and palmar erythema.
spider angiomas and palmar erythema mechanism?
Impaired hepatic metabolism of circulating estrogens, a process that begins in the cytochrome P450 system.
Circulating estrogens affect vascular wall dialtion.
what 3 CP due to hyperestrinism? in men?
gynecomastia, loss of pubic hair, testicular atrophy.
again. Ascites due to portal hypertension. 2?
cirrhosis, cardiac ascites
again. Ascites due to non-portal hypertension. 4?
malignancy, pancreatitis, nephrotic syndrome, TBC
Ascitic fluid characteristic table.
Gross appearance. Typical?
Typically straw-colored and clear
Ascitic fluid characteristic table.
Gross appearance. Bloody?
Suggests trauma or malignancy
Ascitic fluid characteristic table.
Gross appearance. Cloudy?
suggests infection
Ascitic fluid characteristic table.
Gross appearance. milky?
Lymphatic disruption (chylous)
Ascitic fluid characteristic table.
SAAG. >=1,1 indicates what and causes?
indicates portal hypertension.
Causes: cirrhosis, heart failure
Ascitic fluid characteristic table.
SAAG. <1,1 indicates what and causes?
non-portal hypertension
Causes: malignancy, TBC, nephrotic syndrome
Ascitic fluid characteristic table. total protein value?
<2,5 is consistent with cirrhosis or nephrotic syndrome
> =2,5 suggest right heart failure (hepatic congestion)
Ascitic fluid characteristic table. cell count for SBP?
> = 250 neutrophils is diagnostic of SBP
Management of ascites in cirrhosis table. Initial evaluation? 2
Imaging for confirmation (abdominal UG) = shrunken liver and ascites
[shoul be performed in all patients] Diagnostic paracentesis to confirm etiology and rule out infection: SAAG, cell count and differential, total protein
Management of ascites in cirrhosis table. Medical therapy diuretics?
SPIRONOLACTONE WITH FUROSEMIDE
BOTH, not single
promotes natriuresis and prevents electrolyte disturbances
Management of ascites in cirrhosis table. alco, food?
abstinence from alcohol
sodium restriction
Management of ascites in cirrhosis table. what drugs avoid?
ACEI/ARB, NSAIDs
Management of ascites in cirrhosis table. Refractory ascites. Tx 2?
Large volume paracenthesis
TIPS
Why avoid only spironolactone in ascites?
Furosemide alone?
sometimes used in patients prone to hypokalemia
furosemide: alone less effective in this population and predisposes to electrolyte wasting
fluid restriction in ascites to treat hypervolemic hyponatermia?
In hypoNa - okay.
If normal sodium - NOT RECOMMENDED.
severe SBP complication?
paralytic ileus = decr. abdominal sounds and xray findings.
Xray – dilated loops of small and large bowel with air in the colon and rectum.
Hepatic hydrothorax. Cp?
SOB, decr. sounds on auscultation, pleuritic chest pain, hypoxemia
Hepatic hydrothorax. mechanism?
Transudative pleural effusions that are thought to occur due to small defects in the diaphragm.
Hepatic hydrothorax. side?
on the right, because diaphragm is less muscular
Hepatic hydrothorax. Dx?
Detect effusion = xray
other tests to rule out other causes: thoracenthesis, echocardiogram
Hepatic hydrothorax. Tx?
definitive to cirrhosis. diuretics, salt restriction
thoracenthesis - if patient has prominent symptoms
NO chest tube - loss of fluid, electrolytes, proteins, renal failure
