What is probably the most "dreaded" complication of portal hypertension? 

Why is this complication so dreaded?

Fill in the blanks:

Gastroesophageal Varices are present in ___1____% of all chirrhotic pts.  ____2____% will bleed.  ___3___% of initial bleeds are fatal.  Most patients who survive will have a recurrence.

1) 40-60%

2) 25-35%

3) 30%

If someone presents with bleeding gastroeshophageal varices they require a lot of things.  As a matter of fact there are 10 major points that Gayle made.

Name a few:

(Or if you are Sam or Stacey all 10)

1) Prompt aggressive fluid resuscitation

2) Blood transfusions

3) Correction of the coagulopathy

4) ETT intubation for airway protection

5) Upper G.I. scope to find the source

6) Reduction of portal pressure with NONselective beta blockers

7) Endoscopic banding

8) Somatostatin (which is Octreotide) IV

9) Balloon tamponade with a Blakemore/ Minnesota tube  (old school)

10) Transjugular intrahepatic portal system shunt (TIPS)

What are the 4 big pulmonary complications associated with liver failure?

1) CHF

2) Pleural Effusion

3) Insterstitial Edema

4) Pulmonary HTN

1) Liver Failure (with associated problems)

2) Direct Cardiomyopathy

1) What is the most common cause of hypoxemia in the pt with portal HTN/ Liver Failure? 

2) How does the hypoxemia occur?

1) Intrapulmonary vascular dilation

2) The pulmonary alveolar precapillaries dilate close to the alveoli and the capillary beds away from the alveoli dilate.  Both contribute to hypoxemia as the alveolar-arterilal oxygen gradient increases.

1) A mean pulmonary artery pressure > 25 torr signifies what?

2) What do you tell pts with pulmonary artery mean pressures of greater than 35 torr?

1) Pulmonary HTN

2) You aren't getting a liver because you are a poor transplant candidate.   (Might as well go drinking)

1) What is the most common of the major complications of cirrhosis?

2) How does this occur?

1) Ascites

2) Nobody really knows

Fill in the blanks:

___1____% of pts with cirrhosis develop ascites within _____2______ years of being diagnosed.   _____3____% of pts with ascites die  within _____4____ years. 

5) What happens then with the direction of care for this pt?

1) 50%

2) 10

3) 50%

4) 3 

5) This puts them on the transplant list.

1) What can be placed for reoccuring ascites?

2) What can ascites harbor?

1) peritoneal shunts

2) Bacteria- can lead to Bacterial peritonitis

Tell me what I am describing:

This is a functional pre-renal failure.  There is intense vasoconstriction of the renal circulation, low glomerular filtration rate, but preserved renal function.   The intense vasoconstriction is a consequence of extreme vasodilation of the splanchnic arterial circulation reducing blood flow to the kidneys.

Fill in the blanks:

Even _______ hemorrhage can produce ______ hypotensive episodes in the liver failure pt.

1) With Liver failure we will see coagulation disorders.  The coag factors with the ________ 1/2 lives are impacted the most. 

2) Many of these impacted coags reside in which pathway?

3) Specifically- which coag factors are affected the most?

1) Shortest

2) extrinsic

3) II, V, VII, IX, X

If the INR > 1.5 or the PT is greater than 3 seconds above normal (normal being 10-13)

Platelets less than 50,000

FFP 10-20 ml/kg  (the effect is only good for 12-24 hours)

Vitamin K 10 mg SQ for 3 consecutive days.

1) Poor glucose utilization

2) Impaired conversion of lactate to glucose via cori cycle

3) Men undergo feminization

4) Women exhibit irregular periods or amenorrhea

What are my preoperative considerations regarding the chronic liver disease/ Cirrhotic pt?

1) Portal HTN can lead to what? 

2) What do I need to consider regarding fluid resuscitation?

1) GI hemorrhage

2) -Fluid resuscitation must be done carefully to avoid rebleeding of varices

-Vasopressin and octreotide (sandostatin) constrict splanchnic arteriolar bed.