Term
| what are complications of chronic liver disease? |
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Definition
| variceal bleeding, hepatic encephalopathy, ascites, hepatorenal syndrome, recurrent infection, and coagulation abnormalities |
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Term
| what are common causes of ascites? |
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Definition
| portal HTN, hypoalbuminemia, and neoplasms |
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Term
| what is portal HTN? what are common causes? |
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Definition
| portal HTN is hepatic vascular dilatation, engorgement, and collateral circulation due to: hepatic cirrhosis (usually due to alcohol abuse), constrictive pericarditis, budd-chiari syndrome, and IVC syndrome |
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Term
| what characterizes hypoalbuminemia as a cause of ascites? |
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Definition
| in hepatic cirrhosis, the liver is necrotic and scarred and thus is unable to make albumin. albumin is needed to maintain oncotic pressure, and when it is not present, liquid/electrolyes pass into the peritoneal cavity = ascites. other causes of hypoalbumenia can also be due to nephrotic syndrome and protein losing enteropathies such as menetrier's disease |
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Term
| what kinds of neoplasms can cause ascites? |
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Definition
| peritoneal CA, any kind of abdominal CA |
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Term
| what are other causes of abdominal distention besides ascites? |
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Definition
| obesity, pregnancy, gaseous distention of the bowel (gas forming foods – asparagus, broccoli, cauliflower, dairy products), bladder distention (BPH), cyst, and tumors |
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Term
| what needs to be done on pts w/ascites? |
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Definition
| tap the fluid and check macro appearance, do a WBC/eosinophil count, check protein/albumin/amylase levels, and do pap-smear |
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Term
| what might give a false reading for a serum:ascites albumin gradient? |
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Definition
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Term
| what are possible diseases responsible for a high serum:ascities gradient, >11g/L? |
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Definition
| cirrhosis, alcoholic hepatitis, cardiac ascites, budd-chiari, portal vein thrombosis, and veno-occulsive disease. *these are all result of increased pressure in the portal vein |
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Term
| what are possible diseases responsible for a low serum:ascities gradient, <11g/L? |
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Definition
| peritoneal CA, TB peritonitis, pancreatic ascities (rich in protein), biliary ascities, and nephrotic syndrome. *these are all the result of actively secreted fluid due to inflammation or malignancy |
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Term
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Definition
| address the insulting agents/precipitating factors - abstain from alcohol, restrict dietary salt, use mild diuresis (spironolactone - aldosterone antagonist), and watch electrolytes |
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Term
| what is a transjugular intrahepatic portosystemic shunt (TIPPS)? |
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Definition
| running a cath through the liver to the portal vein and tamponading the bleeding, lowering the pressure - which then decreases systemic+splanchnic pressure, decompresses varices, and slows down/collapses collateral circulation |
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Term
| what is portal vein pressure normally? |
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Definition
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Term
| what kind of pressure does portal vein HTN reach? |
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Definition
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Term
| what are the main causes of portal HTN in western countries? worldwide? |
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Definition
| west: alcoholic and viral cirrhosis worldwide: schistosomiasis |
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Term
| can portal HTN lead to varices? |
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Definition
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Term
| what % of GI bleeds are due to varices? |
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Definition
| 7%, and 1/3 of these pts will die |
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Term
| what are factors influencing choice of tx for varices? |
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Definition
| natural course of infection, location of the bleeding varix, residual hepatic function, associated systemic disease, continued drug/alcohol abuse, and response to specific therapy |
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Term
| what are initial measures for tx of varices? |
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Definition
| give dextrose/collioid solution (won't leak out) while wating for type and cross-match of blood, give fresh frozen plasma so clotting factors can get to work and give octreotide (somatostatin analog - reduces gastric motility) which reduces splanchnic pressure |
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Term
| what is therapy for varices due to portal HTN due to chronic liver disease? |
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Definition
| endoscopy to determine location and cauterize, sclerotherapy 20-48 hrs later to get rest of varices, band ligation, and balloon tube tamponade if nothing else works (2 kinds: blakemore-sengstaken and minnesota, latter is better), TIPPS, beta-blockers, and liver transplant |
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Term
| what is hepatorenal syndrome? |
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Definition
| this involves the development of renal failure in pts w/severe liver disease, however the pathophysiology is not well understood. hallmark - severe renal vasoconstriction |
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Term
| what is diagnostic for hepatorenal syndrome? |
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Definition
| low GFR, urine Na+ <10 mmol/L, and urine osmolality > plasma osmolality |
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Term
| what is type I hepatorenal syndrome? |
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Definition
| a rapidly progressive, aggressive disease which impairs renal function marked by a rapid rise in creatinine, GFR less than 20 cc/min, hypotension, and death w/in 8-10 wks - usually not enough time for transplant, but if they get it, they'll be fine. |
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Term
| what is the pathophysiology of hepatorenal syndrome? |
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Definition
| portal HTN causes an increase in splanchnic vasodilators which pools blood, taking it from systemic circulation. systemic vasculature vasconstricts in response, which activates the RAS, leading to Na+ retention (increases pressure) and renal vasoconstriction = hepatorenal syndrome |
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Term
| what is type II hepatorenal syndrome? |
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Definition
| a more insidious, slower progressing illness which begins with development of diuretic-resistant ascites in the abdomen. serum creatinine clearance rises and pts are unable to excrete sufficient Na+. these pts have a median survival of 6 mos - which is enough time to get a transplant. |
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Term
| what are the clinical manifestations for hepatorenal syndrome? |
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Definition
| jaundice, clubbing of fingers, palmar erythema, spider nevi, splenomegaly, bleeding tendencies, edema, ascites, low BP (wide pulse pressure and bounding pulses) |
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Term
| how is type I hepatorenal syndrome managed? |
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Definition
| monitor fluid intake, *watch elecrolyes, restrict fluid intake, cautious use of diuretics, vasoconstrictors such as terlipressin (causes vasoconstriction of splanchnic bed and pushes blood back into systemic circulation), dialysis (not that good), TIPPS (very useful), and liver transplant (best if possible) |
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