Complications of cirrhosis

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Complications of cirrhosis

  1. 1. Complications of Cirrhosis
  2. 2. Table 302 -1 Causes of Cirrhosis Alcoholism Cardiac cirrhosis Chronic viral hepatitis Inherited metabolic liver disease    Hepatitis B    Hemochromatosis    Hepatitis C    Wilson's disease Autoimmune hepatitis          1 Antitrypsin deficiency   Nonalcoholic steatohepatitis    Cystic fibrosis Biliary cirrhosis Cryptogenic cirrhosis    Primary biliary cirrhosis      Primary sclerosing cholangitis      Autoimmune cholangiopathy  
  3. 3. Table 302-2 Complications of Cirrhosis Portal hypertension Coagulopathy    Gastroesophageal varices    Factor deficiency    Portal hypertensive gastropathy    Fibrinolysis    Splenomegaly, hypersplenism    Thrombocytopenia    Ascites Bone disease      Spontaneous bacterial peritonitis    Osteopenia Hepatorenal syndrome    Osteoporosis    Type 1    Osteomalacia    Type 2 Hematologic abnormalities Hepatic encephalopathy    Anemia Hepatopulmonary syndrome    Hemolysis Portopulmonary hypertension    Thrombocytopenia Malnutrition    Neutropenia
  4. 4. Portal hypertension <ul><li>Definition: Elevation of Hepatic venous pressure gradient (HVPG) to >5mmHg </li></ul><ul><li>Causes: increased hepatic resistance to the passage of blood flow through the liver due to cirrhosis and regenerative nodules, and increased splanchnic blood flow secondary to vasodilation of the splanchnic vascular bed </li></ul>
  5. 5. Table 302 -3 Classification of Portal Hypertension Pre-hepatic    Portal vein thrombosis    Splenic vein thrombosis    Massive splenomegaly (Banti's syndrome) Hepatic    Presinusoidal      Schistosomiasis      Congenital hepatic fibrosis    Sinusoidal      Cirrhosis—many causes      Alcoholic hepatitis    Postsinusoidal      Hepatic sinusoidal obstruction (venoocclusive syndrome) Posthepatic    Budd-Chiari syndrome    Inferior vena caval webs    Cardiac causes      Restrictive cardiomyopathy      Constrictive pericarditis      Severe congestive heart failure
  6. 6. Clinical features <ul><li>Gastroesophageal varices </li></ul><ul><li>Ascites </li></ul><ul><li>Hypersplenism </li></ul>
  7. 7. Gastroesophageal Varices <ul><li>1/3 of cirrhotics will have varices on screening endoscopy </li></ul><ul><li>1/3 will develop bleeding </li></ul><ul><li>5-15% will develop varices per year </li></ul><ul><li>Majority will develop varices in their lifetime </li></ul><ul><li>Diagnosis: Endoscopy </li></ul>
  8. 8. Treatment <ul><li>Primary prophylaxis: Beta blocker, Endoscopic variceal ligation (EVL), sclerotherapy </li></ul><ul><li>Prevention of rebleeding: EVL </li></ul><ul><li>Medical therapy </li></ul><ul><li>Somatostatin, Octreotide </li></ul>
  9. 10. TIPS <ul><li>Transjugular Intrahepatic Portosystemic Shunt </li></ul><ul><li>Alternative to surgery for acute decompression of portal hypertension </li></ul><ul><li>Reserved for poor surgical risk, and those who fail endoscopic or medical therapies </li></ul><ul><li>Encephalopathy in 20% </li></ul>
  10. 11. Table 302-2 Complications of Cirrhosis Portal hypertension Coagulopathy    Gastroesophageal varices    Factor deficiency    Portal hypertensive gastropathy    Fibrinolysis    Splenomegaly, hypersplenism    Thrombocytopenia    Ascites Bone disease      Spontaneous bacterial peritonitis    Osteopenia Hepatorenal syndrome    Osteoporosis    Type 1    Osteomalacia    Type 2 Hematologic abnormalities Hepatic encephalopathy    Anemia Hepatopulmonary syndrome    Hemolysis Portopulmonary hypertension    Thrombocytopenia Malnutrition    Neutropenia
  11. 12. Ascites
  12. 13. Clinical History <ul><li>Progressive increase in abdominal girth </li></ul><ul><li>Increase in clothing size </li></ul><ul><li>Appearance of hernias </li></ul><ul><li>Maybe unnoticeable </li></ul><ul><li>Tense ascites causing increased intraabdominal pressure, resulting to reflux symptoms </li></ul><ul><li>Dyspnea, resulting from R sided pleural effusion </li></ul>
  13. 14. Physical Examination <ul><li>Distended abdomen </li></ul><ul><li>Bulging flanks </li></ul><ul><li>Everted umbilicus </li></ul><ul><li>Portal HPN: prominent venous collaterals </li></ul><ul><li>Fluid wave (1.5 L) </li></ul>
  14. 15. Ascites <ul><li>Often accompanied by edema </li></ul><ul><li>Insidious </li></ul><ul><li>Respiratory compromise </li></ul><ul><li>Excessive fatigue </li></ul><ul><li>Muscle wasting </li></ul><ul><li>Malnutrition </li></ul><ul><li>Weakness </li></ul>
  15. 16. Etiologies <ul><li>Cirrhosis </li></ul><ul><li>Congestive heart failure </li></ul><ul><li>Nephrosis </li></ul><ul><li>Malignancy </li></ul><ul><li>Infection (TB, pyogenic) </li></ul><ul><li>Pancreatitis </li></ul>
  16. 18. Table 44-1 Characteristics of Ascitic Fluid in Various Disease States Condition Gross Appearance Protein, g/L Serum-Ascites Albumin Gradient, g/dL Cell Count Other Tests Red Blood Cells, >10,000/      L White Blood Cells, per      L Cirrhosis Straw-colored or bile-stained <25 (95%) >1.1 1% <250 (90%) a ; predominantly mesothelial     Neoplasm Straw-colored, hemorrhagic, mucinous, or chylous >25 (75%) <1.1 20% >1000 (50%); variable cell types Cytology, cell block, peritoneal biopsy Tuberculous peritonitis Clear, turbid, hemorrhagic, chylous >25 (50%) <1.1 7% >1000 (70%); usually >70% lymphocytes Peritoneal biopsy, stain and culture for acid-fast bacilli Pyogenic peritonitis Turbid or purulent If purulent, >25 <1.1 Unusual Predominantly polymorphonuclear leukocytes Positive Gram's stain, culture Congestive heart failure Straw-colored Variable, 15–53 >1.1 10% <1000 (90%); usually mesothelial, mononuclear   Nephrosis Straw-colored or chylous <25 (100%) <1.1 Unusual <250; mesothelial, mononuclear If chylous, ether extraction, Sudan staining Pancreatic ascites (pancreatitis, pseudocyst) Turbid, hemorrhagic, or chylous Variable, often >25 <1.1 Variable, may be blood-stained Variable Increased amylase in ascitic fluid and serum
  17. 19. Ascitic fluid analysis <ul><li>High SAAG gradient: cirrhosis, congestive heart failure, renal failure, Budd Chiari syndrome, hepatic metastases </li></ul><ul><li>Low SAAG gradient: Malignancy, infection </li></ul>
  18. 20. Radiographic Exams <ul><li>Ultrasonography </li></ul><ul><li>CT scan </li></ul>
  19. 21. Table 44-1 Characteristics of Ascitic Fluid in Various Disease States Condition Gross Appearance Protein, g/L Serum-Ascites Albumin Gradient, g/dL Cell Count Other Tests Red Blood Cells, >10,000/      L White Blood Cells, per      L Cirrhosis Straw-colored or bile-stained <25 (95%) >1.1 1% <250 (90%) a ; predominantly mesothelial     Neoplasm Straw-colored, hemorrhagic, mucinous, or chylous >25 (75%) <1.1 20% >1000 (50%); variable cell types Cytology, cell block, peritoneal biopsy Tuberculous peritonitis Clear, turbid, hemorrhagic, chylous >25 (50%) <1.1 7% >1000 (70%); usually >70% lymphocytes Peritoneal biopsy, stain and culture for acid-fast bacilli Pyogenic peritonitis Turbid or purulent If purulent, >25 <1.1 Unusual Predominantly polymorphonuclear leukocytes Positive Gram's stain, culture Congestive heart failure Straw-colored Variable, 15–53 >1.1 10% <1000 (90%); usually mesothelial, mononuclear   Nephrosis Straw-colored or chylous <25 (100%) <1.1 Unusual <250; mesothelial, mononuclear If chylous, ether extraction, Sudan staining Pancreatic ascites (pancreatitis, pseudocyst) Turbid, hemorrhagic, or chylous Variable, often >25 <1.1 Variable, may be blood-stained Variable Increased amylase in ascitic fluid and serum
  20. 22. Treatment <ul><li>Sodium restriction: 2 grams/day </li></ul><ul><li>Spironolactone 100-200 mg/day </li></ul><ul><li>Furosemide 40-80 mg/day </li></ul>
  21. 24. Spontaneous bacterial peritonitis <ul><li>Spontaneous infection </li></ul><ul><li>30% of patients with ascites </li></ul><ul><li>25% mortality rate </li></ul><ul><li>Pathogens: E. coli, Streptococcus, Staph aureus, Enterococcus sp </li></ul><ul><li>Frequency is high in + variceal bleed </li></ul>
  22. 25. Hepatorenal Syndrome <ul><li>Functional renal failure </li></ul><ul><li>10% in advanced cirrhosis or severe acute hepatic failure </li></ul><ul><li>Increase vascular resistance  renal vasoconstriction </li></ul><ul><li>Diagnosis: large amount of ascites with progressive rise in Creatinine </li></ul>
  23. 26. HRS <ul><li>HRS I: progressive impairment in renal function and a significant reduction of Creatinine clearance </li></ul><ul><li>HRS II: reduction in GFR with elevation of serum creatinine (but stable) </li></ul><ul><li>Treatment: Albumin, Somatostatin; Liver transplantation </li></ul>
  24. 27. Hepatic Encephalopathy <ul><li>Alteration in mental status and cognitive function in the presence of liver failure </li></ul><ul><li>More common in chronic liver disease </li></ul><ul><li>Gut-derived neurotoxins </li></ul><ul><li>Elevated ammonia levels, but not a reliable marker for diagnosis </li></ul><ul><li>False neurotransmitters: mercaptans </li></ul>
  25. 28. Precipitating factors <ul><li>Infection </li></ul><ul><li>Increased dietary protein load </li></ul><ul><li>Electrolyte imbalance, ie, hypokalemia </li></ul><ul><li>GI bleeding </li></ul><ul><li>Use of narcotic agents </li></ul>
  26. 29. Treatment <ul><li>Multifactorial </li></ul><ul><li>Treat underlying precipitating factor </li></ul><ul><li>Hydration </li></ul><ul><li>Correction of electrolyte imbalance </li></ul><ul><li>Dietary restriction </li></ul><ul><li>Lactulose </li></ul><ul><li>Antibiotics: Neomycin, Metronidazole </li></ul><ul><li>Zinc supplementation </li></ul>
  27. 30. Malnutrition <ul><li>Factors: poor dietary intake, alteration in gut nutrient absorption, alterations in protein metabolism </li></ul><ul><li>More catabolic  muscle wasting </li></ul><ul><li>Treatment: dietary supplementation </li></ul>
  28. 31. Coagulation abnormalities <ul><li>Decreased synthesis of clotting factors; impaired clearance of anticoagulants </li></ul><ul><li>Hypersplenism  thrombocytopenia </li></ul><ul><li>Platelet function is abnormal </li></ul><ul><li>Vit K dependent factors: II, VII, IX, and X levels are decreased </li></ul>
  29. 32. Hematologic Abnormalities <ul><li>Anemia: hypersplenism, hemolysis, Iron deficiency, Folate deficiency </li></ul><ul><li>Macrocytosis </li></ul><ul><li>Neutropenia </li></ul>

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