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116 Cards in this Set
- Front
- Back
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Histologically, what does cirrhosis look like?
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Regenerative nodules surrounded by fibrous tissue
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What are the two broad complications of cirrhosis?
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Portal hypertension
Liver insufficiency |
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What complications does portal hypertension cause?
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Variceal hemorrhage
Ascites Encephalopathy |
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What complications does liver insufficiency cause?
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Encephalopathy
Jaundice Synthetic dysfunction |
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What complications can ascites cause?
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Spontaneous bacterial peritonitis
Hepatorenal syndrome |
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What is the normal vascular anatomy of the liver?
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SMV, IMV, Splenic vein all feed into portal vein
Hepatic artery comes in Portal vein and hepatic artery are drained by the hepatic vein, which goes into the IVC |
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What happens to the vasculature of the liver in cirrhosis?
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You get hepatoportal circulation due to the high pressure within the liver. This then causes formation of portal systemic capillaries (esophageal batteries)
Also, splenomegaly results as a result of backups |
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Where does most of the increased resistance to flow happen in cirrhosis?
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Sinusoids
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What are some of the non-sinusoidal causes of portal hypertension? What are some causes?
Pre-hepatic? Pre-sinusoidal? Sinusoidal? Post-sinusoidal? Post-hepatic? |
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What happens to vascular tone in cirrhosis?
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Increases!
There's active vasoconstriction |
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What are the structural causes of increased intrahepatic resistance in cirrhosis?
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Sinusoidal fibrosis
Regenerative nodules |
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How does the functional increase in resistance occur in cirrhosis?
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Decreased efficacy of NO
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What happens to blood flow to the liver in portal hypertension?
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Flow is increased due to splanchnic vasodilation (due to INCREASED NO)
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What are the main causes of ascites?
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1. CHRONIC LIVER DISEASE! 80%
Others: Malignancy Heart failure TB Miscellaneous |
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What causes ascites?
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1. Portal venous hypertension (pushes stuff out of the vasculature)
2. Hypoalbuminemia 3. Over-production of lymph |
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What is the major electrolyte abnormalitiy in ascites?
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Sodium retention: the body thinks that it's volume depleted
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What are findings that rule out ascites?
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Negative history of ankle swelling, increased abdominal girth
Inability to demonstrate bulging flanks, flank dullness, or shifting dullness |
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What are the most useful findings for a diagnosis of ascites?
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Positive flulid wave
Shifting dullness Peripheral edema |
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What are indicatations for paracentesis?
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New-onset ascites
Admission to the hospital Clinical deterioration Fever |
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What are the fluid analyses that you should do on a paracentesiss?
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Cell count
Culture Albumin Protein |
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Why do you take a paracentesis albumin as well as a serum albumin on someone with ascites?
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You want to calculate the serum-ascites albumin gradient
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What are causes of a high serum-ascites albumin gradient?
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Cirrhosis; alcoholic hepatitis
Cardiac disease Massive liver mets Fulminant hepatic failure Hepatic outflow block Portal vein thrombosis |
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What are causes of a low serum-ascites albumin gradient?
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Peritoneal carcinomatosis
TB peritonitis Pancreatic duct leak Biliary leak Nephrotic syndrome Serositis |
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What's the cutoff for a serum-ascites albumin gradient?
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1.1 g
Above, high Low, below |
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What's the therapy for ascites?
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Na restriction
Diuretics Large volume paracentesis (for tense ascites) |
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What are some diruetics that you can use in ascites?
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Spironolactone +/- furosemide
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What is refractory ascites?
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Ascites that doesn't respond to diuretics (10%)
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What's the therapy for refractory ascites?
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Large volume paracentesis
TIPS: a stent between the portal vein and the hepatic vein Liver transplantation |
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What does ascites signify in cirrhosis?
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It's a really bad prognostic factor.
50% of your patients will have died after 2 years. |
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What are complications of ascites?
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INFECTION: it's a perfect broth for bacteria-->spontaneous bacterial peritonitis
Tense ascites: problems breathing Umbilical hernia Hydrothorax |
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What is flood syndrome?
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When an umbilical hernia bursts.
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What happens in hydrothorax?
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Fluid from the abdomen (ascitesa) gets through the diaphragm and compresses the lung
Results in infection, problems with normal respiration |
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What are findings in spontaneous bacterial peritonitis?
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Ascitic fluid neutrophil count > 250 cells/mm^3
Positive ascitic fluid culture Lack of obvious intra-abdominal source of infection |
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What are the different kinds of infected ascites?
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Spontaneous bacteiral peritonitis: single org, PMN>250
Monomicrobial nonneutrocytic bacterascites: single org, PMN<250 Culture-negative neutrocytic ascites: no orgs, PMN>250 Secondary bacterial peritonitis: multiple orgs, PMN>250 |
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What are the clinical features of spontaneous bacterial peritonitis?
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Ascites
Fever Abcdominal pain Onset/worsening encephalopathy |
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What are the problems with the presentation of SBP?
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OFTEN THERE AREN'T FINDINGS.
50% have no abdominal findings up to 33% have no clinical features |
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If someone with ascites comes into the ER confused, what do you think?
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SBP until proven otherwise
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What are risk factors for SBP?
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Ascitic fluic concentration is low (no opsoniins)
High serum bilirubin concentrations |
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What proteins are found in the ascitic fluid? What do they do?
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Opsonins
Help to clear bacteria |
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What are the sources of bacteria that get into the abdomen?
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Gut flora
Invasive procedures |
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What are the most common bacteria in ascites?
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E. coli
K. pneumoniae S. pneumoniae There aren't any anaerobes, really. |
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What is the course of someone who has had SBP?
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They're going to get it again.
You need to keep people on bacterial prophylaxis |
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When are prophylactic antibiotics indicated in SBP?
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Cirrhotic patients hospitalized with a GI hemorrhage
People who have recovered from SBP |
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What percentage of people with ascites have esophageal varices?
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60% of patients with ascites
40% of patients with cirrhosis |
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Why do varices bleed?
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Law of LaPlace: the wall gets thin as the varices get larger
What goes on inside, not what goes on outside (GERD, food) makes varices bleed |
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What correlates with the size of esophageal varices?
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Severity of liver disease
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What are predictors of variceal hemorrhage?
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Size
Red signs Child classification of the varix |
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What is the cutoff for variceal bleeding?
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12 mm Hg of portal pressure
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What is the prophylaxis for variceal bleeding?
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Beta-adrenergic blockers
ONLY NON-SELECTIVE BETA BLOCKERS SHOULD BE USED: PROPRANOLOL |
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What's the goal of prophylaxis for varices?
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25% reduction in HR; not <55/min
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What are invasive therapies for varices?
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Band ligation
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What's the management of acute variceal bleeding?
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ABCs
Octerotide: cause splanchnic vasoconstriction Scope them Balloon tamponade: compress the veins |
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What's the therapy for recurrent variceal bleeding?
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Band ligation
Transjugular portosystemic shunt Liver transplant |
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What is portal hypertensive gastropathy?
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Reticulated snake-like skin in the stomach
Blood oozes slowly from the stomach |
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What is the presentation of someone with hepatic encephalopathy?
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Confusion
Reversal of sleep schedule: increasing daytime somnolence |
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What's the survival of people who present with HE?
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42% @ 1 year
23% @ 3 years |
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What is the cause of hepatic encephalopathy?
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Ineffecient clearance of toxins from the blood due to:
-Shunts -Failure to metabolize neurotoxic substances |
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What toxin is particularly implicated in HE?
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Ammonia
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What are the stages of HE?
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1. Mild confusion, limited attention, inverted sleep, incoordination
2. Drowsiness, personality changes, asterixis 3. Somnolent, slurred speech, confused, babinski, muscle rigidity 4. Coma, aresponsive |
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What is asterixis?
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Extend the arms, dorsiflex the wrist.
The hand will droop: the liver flap |
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What are causes of HE?
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HE isn't something itself; it's a presentation of an underlying condition!!!
Infection GI bleed Azotemia Hypokalemia Metabolic alkalosis Increased protein load Constipation, ileus Drugs Progressive liver disease, including HCC |
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What is the relationship between HE and ammonia?
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Associated with hyperammonemia, but ammonia levels DON'T correlate with degree of encephalopathy
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What's the treatment for HE?
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Removal/correction of precipitants
Lactulose Abs: neomycin, metronidazole, rifaximin BZDs: flumazenil |
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What drug should you always prescribe in HE?
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Lactulose
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What is the mechanism of lactulose?
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Osmotc laxative
Alters N metabolism in the colon: traps ammonia Alters GI glutamine metabolism |
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What happens in the hepatopulmonary syndrome?
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Liver disease
Arterial hypoxemia Widespread pulmonary vascular dilation |
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What underlies the pathogenesis fo hepatopulmonary syndrome?
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Increased NO production
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What are signs of hepatopulmonary syndrome?
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Platypnea: dyspnea while upright, relieved by recumbency
Orthodeoxia: worsening hypoxia upon rising to upright |
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What is the underlying problem in hepatopulmonary syndrome?
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Gas exchange problem resulting in arterial hypoxemia
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Other than HPS, what can liver disease do to the lungs?
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Portopulmonary hypertension
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What is the endpoint of portopulmonary hypertension?
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Right heart failure-->death
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What are the effects of cirrhosis on the blood?
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Prolonged prothrombin time
Thrombocytopenia Hypercoaguable state |
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How does cirrhosis cause prolonged prothrombin time?
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Decreased synthesis of vitamin-K dependent clotting factors
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How does cirrhosis cause thrombocytopenia?
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Splenic sequestration/consumption of the blood products
Decreased thromboplastin |
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How does cirrhosis cause a hypercoaguable state?
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Decreased hepatic synthesis of the anticoagulatnt factors: antithrombin III, protein S, protein C
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What are the endocrine effects of cirrhosis in males?
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Decreased androgenization of estrogen:
-Testicular atrophy -Gynecomastia -Spider angiomata -Impotence |
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What are the endocrine effects of cirrhosis in females?
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Anovulation
Amenorrhea Spider angiomata |
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What happens to the kidneys in liver disease?
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Hepatorenal syndrome: kidneys fail
Vasodilitation in the extra-renal circulation; vasoconstriction inside the kidney leading to decreased GFR |
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What are the types of hepatorenal syndrome?
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Type 1: rapidly progressive; bad problems with creatinine clearance
Type 2: slowly progressive |
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What are some causes of azotemia in patients with liver disease?
How do you differentiate between them? |
HRS
Prerenal azotemia Acute tubular necrosis Urine sediment: casts in ATN Response to plasma expansion: prerenal azotemia responds |
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What should you never give someone with HRS?
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NSAIDS
Gentamicin |
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What are risk factors for hepatocellular carcinoma?
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Chronic liver disease
Hepatitis B Mycotoxins Long-term androgenic therapy |
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When should you think HCC in cirrhosis?
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Unexplained cirrhosis
Abnormal hepatic imaging: early enhancement with washout |
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What is the blood test for HCC?
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Alpha-fetoprotein
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What are the worst signs for survivial in cirrhosis?
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HPS
SBP Hepatorenal syndrome |
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What are the factors used in the Child scoring?
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Encephalopathy
Ascites Bilirubin Albumin INR |
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What are the variables used in the model for end-stage liver disease (MELD)?
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Serum total bilirubin
Serum creatinine INR |
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How is the MELD score used in liver transplantation?
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<15; medical management
Transplant in the low 20's |
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What are the causes of cirrhosis?
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NOT HEP A
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What is rapidly becoming a common cause of cirrhosis in the US?
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Non-alcoholic fatty liver disease (NAFLD)
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What are the characteristics of NAFLD?
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Macrovesicular hepatic steatosis occurring in the absence of significant alcohol consumption
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What are the associated conditions with NAFLD?
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Metabolic conditions:
Obesity DM Hyperlipidemia HTN Obstructive sleep apnea Hypothyroidism PCOS Essentially, it's the metabolic syndrome |
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What's the biggest cause of cirrhosis in the US?
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Hepatitis C
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What are some extrahepatic manifestations of hepatitis C?
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Porphyria cutanea tarda
Membranoproliferative glomerulonephritis DM Non-Hodgkin lymphoma Leukocytoclastic vasculitis Mooren's-type corneal ulcerations |
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What is the inheritance of hereditary hemochromatosis?
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Autosomal recessive
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What ethnicity is associated with hereditary hemochromatosis?
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Northern european descent
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What gene is mutated in hereditary hemochromatosis?
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MHC class I disease
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What are the clinical features of hereditary hemochromatosis?
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Arthropathy
DM CHF Impotence, loss of libido BRONZE SKIN! |
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What are the A's of hemochromatosis?
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Asthenia
Arthralgia Aminotransferases (increased) |
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How do you differentiate between hemochromatosis and hemosiderin?
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Where is the iron?
Hepatocytes (hemachromatosis) Kupffer cells (hemosiderin) |
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What is the inheritance of Wilson's disease?
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Autosomal recessive
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What is defective in Wilson's disease?
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Hepatic accumulation of copper due to low ceruloplasmin activity
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What's the treatment for hemachromatosis?
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Phlebotomy: take iron out of the blood.
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What are the clinical features of Wilson's disease?
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KAYSER-FLEISCHER RINGS (in the eyes!
Neurologic findings: Early: incoordination, trumors, ataxia Late: dystonia, seizures, rigidity |
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What's the common initial presentation of Wilson's disease?
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Decreasing performances in school
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What are the laboratory findings of Wilson's disease?
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Decreased serum ceruloplasmin
Elevated nonceruloplasmin serum copper ELEVATED URINE COPPER!!! on 24 hr. urine content |
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What dye do you use for copper?
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Rhodamine
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Who gets primary biliary cirrhosis?
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Middle-aged women
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What is the characteristic finding in the blood of people with primary biliary cirrhosis?
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Anti-mitochondrial antibody
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What are other conditions associated with primary biliary cirrhosis?
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Scleroderma
Sjogren's Arthropathies Thyroiditis Renal tubular acidosis |
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What are the histologic findings in PBC?
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T-lymphocytes attacking bile ducts
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Who gets primary sclerosing cholangitis?
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Men in the 4th and 5th decade
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What condition do men with PSC often have?
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IBD, often ulcerative colitis
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What happens in Budd-chiari syndrome?
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Occlusion of the hepatic veins
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What are common causes Budd-Chiari syndrome?
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Chronic myeloproliferative disorders:
-CML -Polycythemia vera Etc. |
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What are common findings in Budd-Chiari?
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Hepatomegaly
RUQ pain Ascites |
