questions 3

Cirrhosis

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Topic updated on 11/05/17 1:47am

Snapshot
  • A 65-year-old male with a long history of alcohol abuse presents to an emergency room with a painful hemorrhoid. You note severe ascites on exam.

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 portal 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

Evaluation
  • Elevated AST and ALT
    • AST:ALT > 2 suggests alcoholic hepatitis
      • other liver pathologies have ALT > AST
      • inversed because AST is found in the mitochondria and EtOH is a mitochondiral toxin
  • Absolute neutrophilic leukocytosis
    • seen in hepatitis but not fatty change
  • Fasting hypoglycemia
  • Increased anion gap metabolic acidosis
  • Hypertriglyceridemia
  • Hyperuricemia
  • Thrombocytopenia
  • Increased γ-gluamyltransferase
    • secondary to EtOH induced hyperplasia of the smooth ER
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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(M2.GI.14) A 62-year-old white male presents to a primary care doctor with concern for weight gain, abdominal distension, and breast enlargement. Physical exam reveals an overweight male with bilateral gynecomastia and a distended abdomen with evidence of shifting dullness. You also note several skin lesions as demonstrated in Image A. The patient has a past medical history of recurrent gout and Wernicke encephalopathy. Which aspect of the patient's history would reveal the most-likely underlying cause of the patient's chief complaints? Topic Review Topic
FIGURES: A          

1. Surgical history revealing a blood transfusion in 1984
2. Travel history revealing time spent 20 years ago in South America
3. Review of systems revealing constant headaches and nausea that are worse upon waking
4. Social history revealing alcohol abuse
5. Medical history revealing arthritis self-treated with large quantities of acetaminophen

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