Complications of Cirrhosis

Ascites that cannot be mobilized, or early recurrence

Complications

Hepatic encephalopathy, ascites/SBP, Hepatorenal Syndrome, Esophageal varices, Hypersplenism

Manifestations of Chronic Liver Disease

Effects of Portal Hypertension

Esophageal varices, Hematemesis, Peptic Ulcer, Melena, Splenomegaly, Caput medusae, Ascites, Hemorrhoids

Liver Cell Failure

Corna, Scleral Icterus, Fetor Hepaticus, Spider nevi, Gynecomastia, Jaundice, Loss of sexual hair, Liver "flap" Bleeding tendency, Anemia, Testicular atrophy, Ankle Edema

Portal Hypertension

Endoscopy for portosystemic collaterals

Vasodilators/TIPS/Shunts to decrease resistnace

Vasoconstrictors to decrease flow

Pathogenesis

Increased venous hydrostatic Pressure: Cirrhosis leads to constriction of hepatic sinusoids -> lymphatic drainage into abdomen

Avid Renal Retention of Sodium and water: Increased renal sodium absorption along distal tubule secondary to hyperladosteronism

Loss of osmotic pressure: Malnutrition and liver disease (low albumin) -> Fluid moves from intravascular to extravascular space

Compensated Vs Uncompensated

Severe Vasodilation of splanchnic artery

Compensated

Increased CO/Plasma volume restores effective blood volume

Decompensated

Increase CO/Plasma volume not enough to normalize effective arterial blood volume

Sodium and water retention leading to ascites formation

Further activation of vasoconstrictor systems in impairment in cardiac output

Ascites

Gas filled loops of bowel float on top leading to more tympanic at the umbilicus

Shifting dullness

Area of tympany shifts towards teh top

Fluid wave test to feel for waves

Differential Diagnosis

Increased hydrostatic pressure

Cirrhosis, CHF, Constrictive pericarditis, IVC obstruction, Budd-chiari

Decreased osmotic pressure

Nephrotic Syndrome, Protein-losing enteropathy, Malnutrition, Cirrhosis

Fluid production exceeding resorptive capacity

Infections/Neoplasms

Management

Non-pharmaceutical: Sodium Restriction

Diuretics

Aldosterone antagonists more effective than loop diuretics

Side effects: Hyperkalemia, painful gynecomastia, hyponatremia

Refractory Ascites

Ascites that cannot be mobilized, or early recurrence

Either diuretic resistant, or diuretic intractable (complications that do not allow for use of effective diuretic dose)

Requires intervention: Large volume paracentesis. TIPS, Ascites Pump, transplant

Diagnosis

Perform SAAG, Determine if there is portal hypertension

Contraindications: Uncooperative patient, skin infection, pregnancy, severe bowel distension

TIPS: Shunts blood flow to reduce pressure in varices

Spontaneous Bacterial Peritonitis

Clinical Signs

Signs of Peritonitis: Abdo pain, Vomiting, diarrhea, ileus

Signs of Inflammation: Fever, chills, tachycardia, tachypnea, shock

Hepatic encephalopathy, GI Bleeding

Management

Diagnostic Paracentesis -> Gram Stain and Culture

Bedisde innoculation

First line antibiotics: 3rd gen cephalosporin x 5 days

Hepatorenal Syndrome

Splanchnic vasodilation

Reduced effective arterial blood volume, decreased mean arterial pressure

Activation of SNS/RAA System

Renal Vasoconstriction, shift in autoregulatory curve

Cirrhotic cardiomyopathy

Impairment of cardiac function, impaired compensatory increase in cardiac output secondary to vasodilation

Prevention

Avoid neprhotox drugs and IV contrast

Management

IV albumin, Hold diuretics, treat undelying precipinant, target MAP of 75 mmHg

Esophageal Varicces

Treat using: Beta blockage, endoscopic ligation/Sclerotherapy, TIPS

Hepatic Encephalopathy