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Path: Liver 2 - Failure (i) (Varices (30% bleed (30% of bleeds result in…
Path: Liver 2 - Failure (i)
Portal HTN
classified by level/site of origin
causes
hepatic
cirrhosis
initiated by increased resistance to portal blood flow
commonest cause
non-cirrhotic (e.g. portal tract fibrosis due to schisto)
prehepatic (portal vein thrombosis)
posthepatic
Budd Chiari syndrome
rare
obstructed venous outflow from liver
consequences
portosystemic collats develop
extra hepatic: where portal venous + systemic venous circulation anastomose
varices
oesophageal + gastric
risk of bleeds
haematemesis or melena (blood altered by gastric acid)
can also be causes by gastritis or oesophageal tears, esp in alcoholics (do endoscopy to find exact cause)
rectal
peri-umbilical (caput medusae) - dilated abdo wall veins due to collat drainage though portosystemic anastomoses
shunting of portal venous blood - reduced liver perfusion + function
congestive splenomegaly (secondary hypersplenism - low blood counts e.g. platelets)
Varices
30% bleed
30% of bleeds result in death
high rate of recurrence
not all upper GI bleeds are varices - other causes esp in heavy alcohol users
resuscitate + give drugs to reduces portal blood flow
prevent/tx complications (aspiration, infection, HE)
endoscopic tx - band ligation (elastic band deployed @ base of varix) +/- non-selective B-blockers (propranolol)
endoscopic scleropathy not favoured (more complications)
if other tx fails: TIPSS or surgery
primary prevention
screen to identify
tx moderate to severe cases before 1st bleed
secondary prevention
tx to prevent recurrent bleeding
Ascites
fluid in peritoneal cavity
cirrhosis = commonest cause (>80%)
haemodynamic changes a/w portal HTN
water + salt retention
other causes
malignancy (ovarian, GI, lung, breast)
non-cirrhotic portal hypertension
heart failure
pancreatitis
TB
abdo distension
shifting dullness
dx = paracentesis
cell count
microbiology (blood culture bottles most sensitive)
albumin
cytology (malignancy cells, WBCs)
chemistry
Tx
Na restriction
diuretics (spironolactone)
therapeutic paracentesis if refractory (diuretic resistant)
avoid NSAIDs
high index of suspicion for infection
Spontaneous bacterial peritonitis (SBP)
infection of ascites fluid without evidence of surgically txable intra-abdo cause
a/w cirrhosis
E Coli, Klebsiella
early dx + prompt tx = better outcome
subtle/silent presentation
low threshold for paracentesis of ascites fluid
fever, abdo pain/tenderness, altered mental state
tx if ascites fluid cell count > 250 polyps/mm3
antibiotic prophylaxis if high risk (previous SBP or bleed)
HRS
renal impairment secondary to liver disease
haemodymanic effects of portal HTN reduced renal perfusion
typically with ascites
dx of exclusion - no other kidney pathology
hypovolaemia/shock (e.g. infection, bleeding)
acute tubular necrosis (shock or nephrotoxic drugs)
tx resistant, poor prognosis