Cirrhosis and Liver Functions

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Questions and Answers

Which of the following situations warrants a diagnostic paracentesis?

Patients with chronic kidney disease

Patients hospitalized with cirrhotic ascites (correct)

Patients with a history of pancreatitis

Patients presenting with autoimmune disorders

What is an important component of ascitic fluid analysis?

Blood glucose levels

Liver biopsy

Electrolyte panel

Cell count (correct)

What is the optimal daily weight loss when using diuretics for ascites management?

0.2 to 0.4 kg

0.5 to 1.0 kg (correct)

1.0 to 1.5 kg

1.5 to 2.0 kg

Which medication is an aldosterone antagonist used for treating ascites?

Spironolactone Signup and view all the answers

What is a common side effect of diuretic therapy in patients with ascites?

Hyperkalemia Signup and view all the answers

What distinctive complication can arise from excessive diuretic use for ascites?

Deterioration in renal function Signup and view all the answers

When is intravenous infusion of albumin crucial during paracentesis?

Only when over 5 L of fluid is removed Signup and view all the answers

What characterizes refractory ascites?

Adequate sodium restriction and maximal diuretic doses do not lead to desired weight loss Signup and view all the answers

What is the 1-year mortality rate for patients with refractory ascites?

<blockquote> 70% </blockquote> Signup and view all the answers

What is a defining characteristic of cirrhosis?

Conversion of normal liver architecture into abnormal nodules Signup and view all the answers

Which of the following signifies the transition from compensated to decompensated cirrhosis?

Accumulation of ascitic fluid Signup and view all the answers

What is the minimum hepatic venous pressure gradient required for the development of esophageal varices?

10 mm Hg Signup and view all the answers

Which of the following is NOT a common complication of ascites in cirrhosis?

Diabetes mellitus Signup and view all the answers

What factors primarily contribute to portal hypertension in cirrhosis?

Increased resistance to portal venous outflow and hyperdynamic circulation Signup and view all the answers

Which statement accurately describes the mechanism behind ascites formation in cirrhosis?

It results from portal hypertension combined with hypoalbuminemia. Signup and view all the answers

Cirrhosis is classified mainly into which two stages?

Compensated and decompensated Signup and view all the answers

What is the expected median survival time for a patient with decompensated cirrhosis?

2 to 5 years Signup and view all the answers

When is ascites clinically detectable?

When there is fluid accumulation of more than 1 L Signup and view all the answers

What is the primary ant infectious therapy recommended for spontaneous bacterial peritonitis?

Cefotaxime, 1 to 2 g intravenously every 8 hours Signup and view all the answers

Which statement accurately describes the recurrence rate of spontaneous bacterial peritonitis?

Recurrence occurs in 70% of patients within 1 year. Signup and view all the answers

What is a primary disadvantage of antibiotic prophylaxis in patients with cirrhosis?

Development of drug-resistant bacteria Signup and view all the answers

What is the first step in the albumin infusion protocol for treating spontaneous bacterial peritonitis?

1.5 g of albumin per kilogram on day 1 Signup and view all the answers

Which infecting organism is most frequently associated with spontaneous bacterial peritonitis?

Escherichia coli Signup and view all the answers

What additional examination should be performed if the PMN count increases during treatment for spontaneous bacterial peritonitis?

Reexamination for secondary sites of infection Signup and view all the answers

What condition does hepatorenal syndrome (HRS) define?

Functional renal failure without shock Signup and view all the answers

Which of the following therapeutic modalities is the only one proven to improve quality of life and survival in patients with liver disease?

Liver transplantation Signup and view all the answers

Which class of bacteria accounts for approximately 30% of the organisms causing spontaneous bacterial peritonitis?

Gram-positive cocci Signup and view all the answers

When should a repeat paracentesis be indicated in treating a patient?

When the PMN count is greater than baseline and no improvement is observed Signup and view all the answers

Study Notes

Cirrhosis (Body)

Cirrhosis is the final, common histologic pathway for various chronic liver diseases, representing the end stage of liver disease.
The term "cirrhosis" was introduced by Laennec in 1826.
It's derived from the Greek term "scirrhus," referring to the orange or tawny color of the liver seen at autopsy.
Histologically, cirrhosis is a diffuse hepatic process characterized by fibrosis and conversion of normal liver architecture into structurally abnormal nodules.

Definitions

Ascites is a fluid accumulation in the peritoneal cavity; clinically detected when greater than 1 litre.
Portal Hypertension is an increased resistance to portal venous outflow, leading to vasodilation and elevated flow in the splanchnic arterioles.

Function of Liver and storage elements

The liver stores Glucose, Vitamins B12, D, K, Copper, and Iron.
It also degrades insulin, bilirubin, urea, and drugs.

Etiology Factors

Alcohol abuse
Hepatitis B, C, and D infections
Hemochromatosis
Alpha1 antitrypsin deficiency
Wilson's disease
Autoimmune hepatitis

Complications

Ascites
Spontaneous bacterial peritonitis
Gastroesophageal varices (bleeding)
Hepatic encephalopathy
Hepatopulmonary syndrome
Hepatocellular carcinoma

Classification of Cirrhosis

Compensated cirrhosis: without symptoms.
Decompensated cirrhosis: with symptoms such as ascites, esophageal/gastric varices bleeding, hepatic encephalopathy, and jaundice.

Multi-Stage Model

Transition from compensated to decompensated cirrhosis occurs at a rate of approximately 5-7% per year.

Pathophysiology of Decompensated Cirrhosis (DC)

Portal hypertension
Bacterial translocation/PAMPs
Activation of innate pattern recognition receptors
Release of pro-inflammatory molecules (ROS/RNS)
Splanchnic arteriolar vasodilation and cardiovascular dysfunction
Adrenal dysfunction, hepatic encephalopathy (HE), kidney dysfunction (HRS-Hepatorenal syndrome), and hepatic/pulmonary syndrome (HPS)

Types of Ascites

Grade 1: Mild ascites; only detectable by ultrasound.
Grade 2: Moderate ascites; manifest by moderate symmetrical abdominal distension.
Grade 3: Large or gross ascites; provokes marked abdominal distension.

Diagnostic Approach to Ascites

The initial evaluation includes taking a history, a physical examination, and laboratory assessments, including abdominal ultrasound, and liver and renal function tests.
Analysis of ascitic fluid includes a cell count, bacterial culture, and ascitic fluid protein, and albumin.

Cirrhotic Ascites Treatment

A stepped approach to managing cirrhotic ascites includes:
- Bed rest, dietary sodium restriction, fluid restriction
- Spironolactone (aldosterone antagonist), loop diuretics
- Large volume paracentesis with albumin infusion for refractory ascites
  - Paracentesis greater than 5 liters requires 8 to 10 g of albumin infusion for each liter of fluid removed.
  - Less than 5 liters of ascitic fluid can safely be removed without albumin infusion.
Diuretics are used to increase sodium and fluid excretion, with careful monitoring during treatment to avoid complications such as excessive sodium and fluid loss, and hyponatremia.

Refractory Ascites

This occurs in 10-20% of patients, due to impaired renal sodium and water excretion.
Clinical features involve inadequate sodium restriction and maximal diuretic dosing without weight loss response.
Initial treatment involves 400 mg/day of spironolactone, and 160 mg/day of furosemide to compensate for the avid sodium retention.

Reversible Factors for Lack of Response to Diuretic Therapy

Inadequate sodium restriction
Patients taking nephrotoxic medications
Patients with spontaneous bacterial peritonitis
Portal vein or hepatic vein thrombosis
Untreated active liver disease

Treatment Options for Refractory Ascites

Liver transplantation.
Repeated therapeutic paracentesis (large-volume or total).
Transjugular intrahepatic portosystemic shunt (TIPS)

Spontaneous Bacterial Peritonitis (SBP)

An infection of ascitic fluid with no obvious infection source.
It occurs in 10-30% of cirrhotic patients with ascitic fluid.
High recurrence rate is observed in 70% of cases within 1 year.
Organisms include bacterial species such as Escherichia coli, Klebsiella, Streptococcus, and Enterococcus.

SBP Diagnosis

Ascitic fluid analysis, including cell count, Gram stain and culture, albumin, total protein, glucose, lactate dehydrogenase, amylase, bilirubin, and AFB smear and culture (optional).
Diagnostic paracentesis is required in hospitalized patients with cirrhotic ascites and signs of infections, encephalopathy, or deterioration of renal function, and gastrointestinal tract bleeding.
A presumptive diagnosis can be made when more than 250 PMNs per milliliter of ascitic fluid is observed in cirrhotic ascites without a secondary infection source.

SBP Treatment

Empiric antibiotic therapy using cefotaxime (1 to 2 g intravenously every 8 hours).
Amoxicillin-clavulanic acid is administered if the responsible organism is identified.
Albumin infusions (1.5 g per kg bodyweight on day 1 and 1 g/kg on day 3) are now the recommended therapy for spontaneous bacterial peritonitis

Repeat Paracentesis

Performed for patients who did not respond well to previous treatment.
Further evaluation and treatment is needed if the PMN count remains similar to the baseline.

Hepatorenal Syndrome (HRS)

A potentially reversible functional renal failure in advanced liver failure patients with portal hypertension, if no shock or intrinsic nephropathy condition exist.
Type 1 HRS: rapidly progressive renal failure. Doubling serum creatinine to >2.5 mg/dL within less than 2 weeks or a 50% drop in creatinine clearance to <20mL/min.
Type 2 HRS: moderate, steady renal failure with serum creatinine > 1.5 mg/dL. Spontaneous and most common.

HRS Diagnosis

Based on monitoring renal function (serum creatinine and creatinine clearance) and ruling out other causes of kidney dysfunction.

HRS Treatment

Treatment is liver transplantation as the only effective therapy.
Type 2 HRS is managed by discontinuing diuretics and providing plasma volume expansion.
Type 1 HRS could be managed using same procedure plus vasoconstrictor therapy such as Terlipressin.

Hepatic Encephalopathy (HE)

Chronic syndrome of neuropsychiatric symptoms in patients with acute or chronic liver failure that has no primary neurological condition.
HE leads to deterioration in mental status, psychomotor dysfunction, impaired memory, increased reaction time, sensory abnormalities, and coma.

HE Treatment

Finding precipitating factors (e.g., protein excess, infections, GI bleeding, sedatives, diuretics, acidosis, hyponatremia) and treating them.
Avoiding analgesics, sedatives, and tranquilizers.
Controlling gastrointestinal tract bleeding.
Screening and aggressive therapy for any infection.
Correcting acidosis, alkalosis, hypoxia, and electrolyte abnormalities.
Preventing constipation and intravascular volume depletion.
Ensuring adequate glucose intake.
Using rifaximin (oral antibiotic) to reduce ammonia and nitrogenous waste formation.
Liver transplant.

Additional note:

The information provided above is for study purposes only and should not be considered medical advice. Always consult with a healthcare professional for any health concerns.

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Description

This quiz explores the essential aspects of cirrhosis, including its histological characteristics, definitions of related medical terms, and the liver's storage and functional roles. Test your knowledge on etiology factors contributing to liver disease and critical elements related to liver health.