Liver Cirrhosis

Front 1

What is another name for vasopressin?

Back 1

Antidiuretic hormone

Front 2

What is the first step to the pathophysiology in cirrhosis?

Back 2

Injury to hepatocellular elements (alcohol, infection, etc)

Front 3

What is the second step to the pathophysiology in cirrhosis?

Back 3

Inflammatory response with cytokine release

Front 4

What is the third step in the pathophysiology in cirrhosis?

Back 4

Fat storing cells in the liver, or stellate cells, begin to resemble fibroblasts and actively engage in extracellular matrix production depositing fibrous material within the sinusoids disrupting the normal blood flow through the hepatic lobule.

Front 5

What is the fourth step in the pathophysiology in cirrhosis?

Back 5

Destruction of hepatocytes, bile duct cells, vascular endothelial cells

Front 6

What is the normal function of hepatic stellate cells?

Back 6

Storage of retinoids like vitamin A

Front 7

Where do hepatic stellate cells normally reside?

Back 7

In the sinusoidal space (special blood vessel)

Front 8

What does cirrhosis of the liver do to the flow of nutrients and vascular blood flow?

Back 8

Prevents the normal flow of nutrients to hepatocytes and increase vascular resistance

Front 9

Is fibrosis of the liver in cirrhosis reversible?

Back 9

yes, if inciting events are removed during the initial stage of injury

Front 10

What occurs with the progressive deposition of fibrous material within the sinusoids during cirrhosis of the liver?

Back 10

Disruption occurs with the normal blood flow leading to elevations in porktal blood pressure or portal hypertension

Front 11

What are the common etiologies of hepatic cirrhosis?

Back 11

Alcohol, biliary obstruction (biliary atresia / neonatal hepatitis, congenital biliary cysts, cystic fibrosis), primary or secondary biliary cirrhosis, chronic hepatitis B or C, hemochromatosis, NAFLD (usually secondary to obesity, also can occur after jejunoileal bypass)

Front 12

What are the drug and toxin induced causes of hepatic cirrhosis?

Back 12

Methyldopa, amiodarone, INH, MTX, Vitamin A

Front 13

What are the immune-mediated induced causes of hepatic cirrhosis?

Back 13

Autoimmune chronic hepatitis

Front 14

What are the genetic metabolic disease induced causes of hepatic cirrhosis?

Back 14

alpha1-antitrypsin deficiency, amino acid disorders, bile acid disorders, lipid disorders, Porphyria (A rare hereditary disease in which the blood pigment hemoglobin is abnormally metabolized)

Front 15

What are the infectious causes of hepatic cirrhosis?

Back 15

Brucellosis, Congenital or tertiary syphyllis, Schistosomiasis

Front 16

What are the vascular abnormalities that cause hepatic cirrhosis?

Back 16

Rt-sided heart failure, pericarditis

Front 17

What are the idiopathic causes of hepatic cirrhosis?

Back 17

Sarcoidosis, Idipathic portal fibrosis

Front 18

What are the important epidemiologic notes about cirrhosis?

Back 18

Affects 3.6/1k persons in the US, 12th leading cause of death in US in 2000 (>27k deaths annually), 4th leading cause of death among 45-54 year olds; american indian, alaskan native and hispanic populations more affected than others

Front 19

What are the clinical presentations of early and well-compensated cirrhosis?

Back 19

anorexia, weight loss, weakness/fatigue, osteoporosis (Vit D deficiency)

Front 20

What are the clinical presentations of decompensated cirrhosis?

Back 20

ascites, SBP (spontaneous bacterial peritonitis), hepatic encephalopathy, variceal bleeding, jaundice of eyes or skin, pruritis, coagulaopathy

Front 21

What are the physical findings of cirrhotic patients in relation to the effects of portal hypertension?

Back 21

Esophageal varices (lead to melena and hematemesis), splenomegaly, dilated abdominal viens (caput medusae), ascites, rectal varies (hemorrhoids)

Front 22

What are the physical findings of cirrhotic patients in relation to the effects of liver cell failure?

Back 22

Coma, fetor hepaticus (death breath), spider nevi, gynecomastia, jaundice, ascites, loss of sexual hair, testicular atrophy, liver 'flap' (coarse hand tremor), bleeding tendency (decreased PT), anemia macrocytic iron deficiency (blood loss), ankle edema

Front 23

What is another term for coarse hand flap associated with liver cirrhosis?

Back 23

Asterixis

Front 24

What causes fector hepaticus?

Back 24

increase in dimethylsulfide concentrations

Front 25

What physical findings in liver cirrhosis are related to altered sex hormone metabolism?

Back 25

Spider angiomata, gyneocomastia, testicular atrophy

Front 26

What are the labs typically done for liver cirrhosis?

Back 26

Liver panel (ALT, AST, GGT), CBC with platelets, prothrombin time

Front 27

What is AST?

Back 27

Aspartate aminotransferase

Front 28

What is ALT?

Back 28

Alanine aminotransferase

Front 29

Do normal aminotransferases preclude rirrhosis dx?

Back 29

No

Front 30

What is the ration of AST to ALT in acute liver injury?

Back 30

2 AST : 1 ALT

Front 31

What is MELD?

Back 31

Mayo End-Stage Liver Disease or Model for End-Stage Liver Disease

Front 32

Are alkaline phosphatase and GGT (gamma-glutamyl transpeptidase) found solely in the liver?

Back 32

No

Front 33

What is the cobination of an elevation in alkaline phosphatase level with a concomitant elevation in GGT level a marker of?

Back 33

Considered to be both a sensitive and specific marker of cholestatic liver disease

Front 34

What is the significance of an increase in the level of bilirubin in liver cirrhosis?

Back 34

Elevations are common in end stage liver disease, degree of elevation has prognostic significance; can also be elevated in common bile duct obstruction, gallstones, and malignancy

Front 35

What is the significance of a decrease in Albumin?

Back 35

Levels decline as liver function declines, decrease is not specific to cirrhosis (can occur in CHF, nephrotic syndrome, malnutrition)

Front 36

Where is albumin synthesized?

Back 36

exclusively in the liver

Front 37

What is the significance of an increase in PT?

Back 37

An increase in prothrombin time reflects the degree of hepatic dysfunction

Front 38

What is the significance of a decrease in serum sodium in liver cirrhosis?

Back 38

Common in cirrhosis and ascites; related to an inability to excrete free water

Front 39

What is the significance of anemia?

Back 39

Multifactorial in origin (GI losses, direct toxicity secondary to alcohol, hypersplenism, bone marrow suppression)

Front 40

What is the significance of lowered platelets?

Back 40

Mainly caused by portal hypertension with attendant congestive splenomegaly

Front 41

What is the significance of leukopenia and neutropenia in liver cirrhosis?

Back 41

due to hypersplenism

Front 42

What is the the significance of coagulation defects in liver cirrhosis?

Back 42

most of the proteins involved in the coagulation process are produced in the liver; can also develop varying degrees of DIC, fibrinolysis, vitamin K deficiency, dysfibrinogenemia, and thromobocytopenia resulting in increased bleeding

Front 43

What is the gold standard of diagnosis of cirrhosis?

Back 43

biopsy

Front 44

What are the diagnostic imaging tests for liver cirrhosis?

Back 44

ultrasound, computed tomography, magnetic resonance imaging

Front 45

What are the advantages and uses of ultrasound in diagnosing liver cirrhosis?

Back 45

Non-invasive, well tolerated, widely available. Can be used as a screening test for hepatocellular carcinoma and portal hypertension

Front 46

What are the advantages and disadvantages of computed tomography?

Back 46

provides similar information as ultrasound but with added exposure to radiation, contrast, and cost

Front 47

Why is magnetic resonance imaging not routinely used for diagnosing liver cirrhosis?

Back 47

$$$$$

Front 48

What are the two types of liver disease scoring systems?

Back 48

Child-Pugh Classification and Model for End-Stage Liver Disease Scoring (MELD)

Front 49

What are the two type of manifestations that Child-Pugh Classification quantifies in cirrhotic process?

Back 49

laboratory and clinical manifestations

Front 50

What are the potential problems of the Child-Pugh Classification?

Back 50

the classification is subjective due to the measurements in ascites and encephalopathy

Front 51

In the Child-Pugh Scoring of liver disease, what is the score of Grade A?

Back 51

<7 points

Front 52

In the Child-Pugh Scoring of liver disease, what is the score of Grade B?

Back 52

7-9 points

Front 53

In the Child-Pugh Scoring of liver disease, what is the score of Grade C?

Back 53

10-15 points

Front 54

In the Child-Pugh Scoring of liver disease, what is the score if bilirubin is < 2 mg/dl?

Back 54

1

Front 55

In the Child-Pugh Scoring of liver disease, what is the score if bilirubin is 2-3 mg/dl?

Back 55

2

Front 56

In the Child-Pugh Scoring of liver disease, what is the score if bilirubin is > 3 mg/dl?

Back 56

3

Front 57

In the Child-Pugh Scoring of liver disease, what is the score if Albumin is > 3.5 g/dl?

Back 57

1

Front 58

In the Child-Pugh Scoring of liver disease, what is the score if Albumin is 2.8-3.5 g/dl?

Back 58

2

Front 59

In the Child-Pugh Scoring of liver disease, what is the score if Albumin is < 2.8 g/dl?

Back 59

3

Front 60

In the Child-Pugh Scoring of liver disease, what is the score if there are no ascites?

Back 60

1

Front 61

In the Child-Pugh Scoring of liver disease, what is the score if there are mild ascites?

Back 61

2

Front 62

In the Child-Pugh Scoring of liver disease, what is the score if there are moderate ascites?

Back 62

3

Front 63

In the Child-Pugh Scoring of liver disease, what is the score if there is no encephalopathy?

Back 63

1

Front 64

In the Child-Pugh Scoring of liver disease, what is the score if there is grade 1-2 encephalopathy?

Back 64

2

Front 65

In the Child-Pugh Scoring of liver disease, what is the score if there is grade 3-4 encephalopathy?

Back 65

3

Front 66

In the Child-Pugh Scoring of liver disease, what is the score if there is a PT of < 4 sec or an INR of <1.7?

Back 66

1

Front 67

In the Child-Pugh Scoring of liver disease, what is the score if there is a PT of 4-6 sec or an INR of 1.7-2.3?

Back 67

2

Front 68

In the Child-Pugh Scoring of liver disease, what is the score if there is a PT of > 6 sec or an INR of > 2.3?

Back 68

3

Front 69

What is the equation for MELD score?

Back 69

0.957 x Loge(SCr)
+ 0.378 x Loge(Bilirubin)
+ 1.120 x Loge(INR)
+ 0.643

Front 70

What is the estimate of 3 month mortality for a MELD score of 40 or more?

Back 70

71.3%

Front 71

What is the estimate of 3 month mortality for a MELD score of 30-39?

Back 71

52.6%

Front 72

What is the estimate of 3 month mortality for a MELD score of 20-29?

Back 72

19.6%

Front 73

What is the estimate of 3 month mortality for a MELD score of 10-19?

Back 73

6.0%

Front 74

What is the estimate of 3 month mortality for a MELD score of < 9?

Back 74

1.9%

Front 75

What is UNOS?

Back 75

United Network for Organ Sharing (evaluate the need of pt for liver based off of MELD score)

Front 76

What are the pharmacodynamic changes in liver failure?

Back 76

changes in volume of distribution, increased sensitivity (opiates, bzds, nsaids)

Front 77

What happens to Phase I metabolism in liver failure?

Back 77

Phase I metabolism (hydrolysis, oxidation, dealkylation, reduction) tends to be significantly impaired

Front 78

What happens to Phase II metabolism in liver failure?

Back 78

Phase II metabolism (conjugation) remains relatively unaffected

Front 79

How is lorazepam metabolized and does it have any active metabolites?

Back 79

metabolized by conjugation and has no active metabolite

Front 80

How is diazepam metabolized and does it have any active metabolites?

Back 80

Metabolized by oxidation and has active metabolites

Front 81

What is the reduction in dose of Tigecycline in Child Pugh Class C?

Back 81

50% dose reduction

Front 82

What drugs mentioned in lecture should have a dose reduction in liver cirrhosis?

Back 82

Tigecycline, clindamycin, caspofungin

Front 83

What are the 5 non-pharmacologic supportive strategies in hepatic failure?

Back 83

Osteoporosis screening, vaccinations, nutrition, alcohol abstinence, tobacco abstinence

Front 84

What are the treatments for osteoporosis?

Back 84

bisphosphonates, Calcium 1500mg/d, selective estrogen receptor modulator (wm), calcitonin, testosterone in men

Front 85

What vaccinations should a liver cirrhosis receive?

Back 85

Hep A&B, Pneu, Flu

Front 86

How does cirrhosis impair nutritional metabolism?

Back 86

Cirrhosis impairs hepatic function and causes decreased glucose, protein, and lipid metabolism

Front 87

What is PCM?

Back 87

protein calorie malnutrition; is common in advanced liver disease with weight loss, nausea, and anorexia

Front 88

What complications in liver cirrhosis is PCM associated with?

Back 88

increased risk for infections, esophageal variceal bleeding, and both renal and pulmonary complications

Front 89

Why should raw seafood be avoided in pts with cirrhosis?

Back 89

risk of septicemia with Vibrio vulnificus

Front 90

Can alcohol abstinence offer improvement to a pt with decompensated liver disease?

Back 90

yes, can improve survival

Front 91

What are the benefits of tobacco abstinence for a liver cirrhosis pt?

Back 91

liver is a target of many carcinogens in tobacco, many liver transplant programs will not offer tranplant to patients that smoke, smoking is associated with hepatic artery thrombosis if the patient continues to smoke post transplant

Front 92

What are the non-pharmacologic treatments for liver cirrhosis?

Back 92

slowing/reversing liver disease progression(treat underlying cause), prevent superimposed insults (avoid hepatotoxic substances, do not exceed 2g apap/d), prevent complications, determine appropriate liver transplant timing, proper nutrition (take a multivitamin)

Front 93

What are the indications for liver transplant?

Back 93

fulminant hepatic failure, decompensated cirrhosis (incl hepatorenal syndrome), hepatocellular carcinoma

Front 94

What are the contraindications for liver transplant?

Back 94

Multisystem organ failure, extrahepatic or extrabiliary malignancy or infection, advanced cardiac or pulmonary disease, HIV, active alcohol or illicit substance abuse

Front 95

What are the relative contraindications for liver transplant?

Back 95

renal insufficiency, hemochromatosis, sponateous bacterial peritonitis, age greater than 65, inability to comply with immunosuppression regimen