questions 3

Cirrhosis and Portal Hypertension

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Topic updated on 12/13/16 7:11pm

Snapshot
  • A 55-year-old man presents to his primary care physician complaining of yellow skin and abdominal swelling. He thought he might be gaining some weight but noticed strange vascular markings around his umbilicus that have concerned him. He has a history of alcohol abuse and most recently has been drinking a liter of vodka on a daily basis. 
Introduction
  • Irreversible liver damage resulting in fibrosis
    • hepatocytes regenerate forming nodules but have abnormal architecture
    • there are 2 types of nodules
      • micronodular
        • nodules < 3 mm, uniform size
        • follows metabolic insult
      • macronodular
        • nodules > 3 mm, varied size
        • hepatic necrosis
        • ↑ risk of hepatocellular carcinoma
    • nodules increase vessel pressure in the sinusoids
    • results in congestion of the poral vein
  • Causes 
    • similar etiologies to hepatitis
    • alcohol (micronodular)
      • most common cause in the United States.
    • metabolic (micronodular)
      • Wilson's
      • hemochromatosis
    • chronic viral hepatitis  (macronodular)
      • results in a specific "post-necrotic" cirrhosis
    • drug-induced (macronodular)
    • autoimmune
      • primary biliary cirrhosis
      • autoimmune hepatitis
  • Both lead to an increased risk of hepatocellular carcinoma
Presentation
  • Physical exam 
    • caused by two main disease processes
      • hepatic failure
        • palmar erythema
        • Dupuytren's contracture
        • encephalopathy
          • ↓ excretion of ammonia
          • worse in alkalemic states
            • NH3 favored over NH4+
        • jaundice
          • ↓ excretion of billirubin
        • pitting ankle edema
          • ↓ synthesis synthesis of albumin
        • gynecomastia/spider angiomas/female hair distribution 
          • ↓ degradation of estrogens
        • bleeding (↑ PT)
          • ↓ synthesis of coagulation factors
        • asterix
          • "flapping" tremor
      • portal hypertension
        • hepatosplenomegaly
          • splenomegaly is secondary to portal hypertension
        • caput medusae
        • ascites
          • also due to hypoalbuminemia, secondary hyperaldosteronism

Treatment
  • Surgical
    • liver transplant
    • portal shunting
      • portacaval
        • portal → hepatic vein
      • mesocaval
        • SMV → vena cava
      • splenorenal
        • splenic vein→ renal vein
      • transjugular intrahepatic portosystemic
        • portal → hepatic vein
Prognosis, Prevention, and Complications
  •  Complications of portal hypertension
    • esophageal varices
      • may rupture resulting in massive hematemesis
    • hemorrhoids
    • spontaneous bacterial peritonitis


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