W6 Cirrhosis Flashcards
What does cirrhosis look like histologically?
Ring of fibrosis around hepatocytes
What cells in the liver undergo transformation when there is chronic inflammation and where are these cells?
Hepatic stellate cells in the space of Disse
What 4 blood vessels drain into the portal vein?
- gastric vein
- splenic vein
- superior mesenteric vein
- part of inferior mesenteric vein
From what 5 structures does the portal vein carry outflow to the liver?
- spleen
- oesophagus
- stomach
- pancreas
- small + large intestine
From what two blood vessels does blood enter the liver sinusoids and describe the blood from each (oxygenated/deozygenated)?
- Hepatic artery -> oxygenated blood from celiac trunk
- hepatic portal vein -> deoxygenated nutrient rich blood
From what blood vessel does the blood leave the liver and where does it drain to?
Leaves through the hepatic vein and drains into the IVC
What is the approximate blood pressure of the hepatic portal vein?
5-8 mmHg
What are the four sites of anastomosis where the portal venous system joins with the systemic venous system ?
- oesophageal and gastric venous plexus
- retroperitoneal collateral vessels
- umbilical vein from the left portal vein to the epigastric venous system
- hemorrhoidal venous plexus (in rectum)
What does the lack of liver blood flow cause the liver to produce? (in addition to causing portal hypertension)
Causes increased production of vasodilators, enhanced sensitivity to vasodilators and resistance to vasoconstrictors
What does cirrhosis lead to in splanchnic blood vessels?
Splanchnic arteriolar vasodilation
What effect does splanchnic arteriolar vasodilation have on CO, SVR and MAP?
CO increases
SVR decreases
MAP decreases
What does increased CO with decreased SVR and MAP cause activation of?
activation of arterial baroreceptors
What effect does activation of arterial baroreceptors have on HR and CO?
HR increases
CO increases
Increase in HR and CO due to splanchnic arteriolar vasodilation causes activation of which vasoconstrictors?
- Sympathetic Nervous System
- RAAS
- AVP - Arginine vasopressin
- ET -> endothelin
What does activation of SNS, RAAS, AVP and ET lead to in the renal system and retention of?
- renal vasoconstriction
- sodium and water retention
Why is portal hypertension thought to be worse in patients with cirrhosis?
Because there is resistance to outflow and an increase in inflow into portal circulation
What are 2 prehepatic causes of portal hypertension i.e. 2 causes of portal vein blockage?
- portal vein thrombosis
- occlusion secondary to congenital portal venous abnormalities (e.g. premature babies with cannulised umbilical vein)
What can protein S, protein c or MP thrombin 3 deficiencies cause?
pro thrombotic conditions
List 2 presinusoidal intrahepatic causes of portal hypertension?
- Schistosomiasis
- non-cirrhotic portal hypertension
What are Budd-Chiari syndrome and veno-occlussive disease examples of ?
Outflow obstruction problems
List 3 examples of postsinusoidal intrahepatic portal hypertension?
- cirrhosis
- alcoholic hepatitis
- congenital hepatic fibrosis
What is difference between compensated cirrhosis and decompensated cirrhosis?
-Compensated -> appear normal outside
,mildly abnormal findings clinically -Decompensated -> liver failure due to acute/chronic infection/insult/SIRS or end stage liver disease
What 6 clinical signs might you find in patient with compensated cirrhosis?
- spider naevi
- palmar erythema
- clubbing
- gynaecomastia
- hepatomegaly
- spleenomegaly
- OR none
What additional 4 clinical signs are found in patients with decompensated cirrhosis?
- jaundice
- ascites
- encephalopathy
- bruising
What is schistosomiasis?
acute and chronic disease caused by parasitic worms
Why does loss of liver function lead to encephalopathy?
Decreased urea synthesis in liver leads to increased blood ammonia causing encephalopathy
Decreased synthesis of what leads to ascites?
Albumin
What are 5 complications of cirrhosis?
- hepatocellular carcinoma
- liver failure
- variceal bleeding
- encephalopathy
- ascites
Why is nutrition an important factor when treating patient with decompensated cirrhosis?
They have low threshold to switch to gluconeogenesis and lypolysis and catabolism due to limited glycogen stores
Why are small frequent meals and snacks recommended for patients with decompensated cirrhosis?
As they quickly switch to gluconeogenesis and muscle catabolism especially at night
What vitamin is mandatory for decompensated cirrhotics with excess alcohol intake and why?
Vitamin B1 (thiamine) cos it helps use carbs as energy
What is target input of sodium in low sodium diet?
100mmol/day
What tests can you do to check sodium levels in urine?
24hr urinary sodium excretion
-spot urine (if Na>K then 90% PPV that 24hr Na excretion>80mm)
What are 7 treatment options in ascites?
- low sodium diet
- improve underlying disease
- drugs: no NSAIDs or sodium heavy drugs
- diuretics
- parancentesis
- TIPSS
- Transplantation
What is first line diuretic in new escalated ascites?
Spironolactone
What is prescribed in addition to spironolactone in recurrent ascites?
Loop diuretic e.g. furosemide
What must be carefully monitored in dose change or paracentesis in ascites?
-U&es
What are risks of paracentesis?
Risk of infection
- encephalopathy
- hypovolaemia
What is administered with paracentesis to prevent hypovolaemia?
albumin
What occurs in TIPSS procedure?
Shunt created between hepatic portal vein and hepatic vein to prevent variceal bleeding and ascites
What is SBP and what is prognosis?
Spontaneous Bacterial Pertionitis -> bacteria from gut is translocated into ascites
-prognosis usually poor
What is treatment for SBP?
- antibiotics
- albumin
- vascular instability treat with terlipressin
- maintain renal perfusion
What is investigations for SBP?
Do a tap in all ascites and cell count
What can encephalopathy mimic in clinical signs?
Alcohol withdrawal
3 clinical signs of encephalopathy?
- flap
- confusion
- tremor
Through what 3 pathways is ammonia generated in the body?
- deamination of glutamine by glutaminase
- metabolism of nitrogenous substances by colonic flora
- in the intestines from nitrogenous compounds from the diet
Where is ammonia metabolised to urea?
In the liver
What can cause a rise in blood ammonia?
Portal-systemic shunts and liver failure
What can does increased blood ammonia affect astrocytes?
- can impair mitochondrial astrocytes
- can impair glutamine-glutamate trafficking between astrocytes and neurons
What muscle can decrease blood ammonia by converting it to glutamine?
Skeletal muscle
List 4 possible causes of encephalopathy.
- liver failure
- drugs e.g. sedating drugs
- metabolic derangements e.g. electrolytes
- infection
Why is patient with encephalopathy given lactulose?
To clear gut so colonic flora has less time to produce ammonia
Why are small frequent meals encouraged in encephalopathy?
To reduce fasting gluconeogenesis and muscle catabolism
What non-absorbed antibiotic is sometimes given to patients with encephalopathy and why?
- Rifaximin
- Reduces bacterial load of gut and changes pH
What is primary prophylaxis treatment for patient with eosophageal varices?
- Non selective beta blockers e.g. propranolol and carvideolol
- variceal ligation
What is treatment for acute variceal bleeding?
- Resuscitation
- Vasoconstrictor -> terlipressin
- Variceal banding
- TIPSS
What is treatment if bleeding can’t be stopped in variceal bleeding?
Balloon tamponade -> Gastric balloon
What is risk in balloon tamponade in variceal bleeding?
Blood aspirated into lungs and aspiration pneumonia as a result
What is secondary prophylaxis of variceal bleeding following acute variceal bleed?
Both variceal band ligation and beta blockers
Why are cirrhotic patients more prone to both excessive bleeding and blood clotting?
Liver makes both clotting factors and anti-clotting factors so when clotting factors low so are anti-clotting factors
What blood test measures how long it takes the blood to clot?
Prothrombin time
What scoring system is used to place patients on liver transplant list and what score does patient need to be listed?
UKELD score of > 49
