Health Risks: Morbidity and Mortality Factors
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Which of the following is an increasing reason for morbidity and mortality but remains less common than heart disease, cancer, and stroke?

  • Cirrhosis (correct)
  • Pancreatitis
  • Gastroesophageal reflux disease (GERD)
  • Gallstones

    • Who typically manages the majority of liver-related conditions such as cirrhosis and chronic viral hepatitis?

  • Cardiologists
  • Hepatologists (correct)
  • Oncologists
  • Nephrologists

    • Who typically manages the majority of liver-related conditions such as cirrhosis and chronic viral hepatitis?

  • Cardiologists
  • Hepatologists (correct)
  • Oncologists
  • Nephrologists

    • Which of the following is NOT a recognized cause of liver damage?

    <p>High blood pressure</p> Signup and view all the answers

    What is the primary function of hepatic stellate cells in the liver?

    <p>Storage of vitamin A</p> Signup and view all the answers

    What is the consequence of drinking excessive alcohol over time on the liver?

    <p>Fatty liver disease</p> Signup and view all the answers

    Which of the following statements about the blood supply to the liver is correct?

    <p>The liver has a dual blood supply from the hepatic artery and portal vein.</p> Signup and view all the answers

    In liver anatomy, what separates the plates of hepatocytes?

    <p>Sinusoids</p> Signup and view all the answers

    What is the impact of portal hypertension on renal function?

    <p>Decreases renal perfusion and glomerular filtration rate.</p> Signup and view all the answers

    Which complication is commonly associated with decompensated cirrhosis?

    <p>Hepatorenal syndrome</p> Signup and view all the answers

    What physiological change leads to ascites in the setting of portal hypertension?

    <p>Higher mean hydrostatic pressure and lower oncotic pressure.</p> Signup and view all the answers

    How does the body's response to splanchnic vasodilation affect blood flow?

    <p>It increases blood flow to the intestines and simultaneously increases portal pressure.</p> Signup and view all the answers

    What is the prognosis of compensated cirrhosis compared to decompensated cirrhosis?

    <p>Decompensated cirrhosis has a much lower median survival rate.</p> Signup and view all the answers

    What role does the renin-angiotensin-aldosterone system play in response to portal hypertension?

    <p>It causes sodium and water retention to compensate for low blood volume.</p> Signup and view all the answers

    Which of the following is least likely to trigger the decompensation of compensated cirrhosis?

    <p>Increasing physical activity</p> Signup and view all the answers

    What is a common consequence of intrahepatic porto-systemic shunts?

    <p>Reduced perfusion of the liver.</p> Signup and view all the answers

    What factor primarily contributes to the 'capillarisation' of sinusoids in chronic liver disease?

    <p>Increased portal pressure leading to liver fibrosis.</p> Signup and view all the answers

    Which therapy is typically used to manage portal hypertension?

    <p>Transjugular intrahepatic porto-systemic shunt (TIPS)</p> Signup and view all the answers

    What is the primary function of bile formed by hepatocytes?

    <p>To assist in digestion by emulsifying fats</p> Signup and view all the answers

    In relation to liver anatomy, what best describes the acinus?

    <p>A functional unit associated with one portal tract and adjacent lobules</p> Signup and view all the answers

    What is the most significant consequence of chronic passive venous congestion in the liver?

    <p>Formation of 'nutmeg liver'</p> Signup and view all the answers

    What is the effect of ischaemic injury to the liver?

    <p>Marked elevation of liver blood tests</p> Signup and view all the answers

    What type of injury is characterized by bridging necrosis in the liver?

    <p>Extensive cell death connecting portal tracts and central vein</p> Signup and view all the answers

    Which of the following defines cirrhosis?

    <p>Diffuse distortion of liver architecture with fibrous bands</p> Signup and view all the answers

    What role does the common bile duct play in liver function?

    <p>Drain bile from the liver into the duodenum</p> Signup and view all the answers

    What is the outcome of ongoing liver damage without acute liver failure?

    <p>Progression to chronic liver disease</p> Signup and view all the answers

    Which factor most significantly affects the susceptibility to ischaemic hepatitis?

    <p>Chronic cirrhosis or venous congestion</p> Signup and view all the answers

    In the assessment of liver damage, which method is used to evaluate fibrosis stage?

    <p>Liver biopsy with trichrome staining</p> Signup and view all the answers

    What is the primary reason for increased hepatic resistance to portal blood flow in cirrhosis?

    <p>Structural changes due to fibrosis</p> Signup and view all the answers

    What is characteristic of the liver in cases of chronic liver inflammation?

    <p>Increased risk of hepatocellular carcinoma</p> Signup and view all the answers

    How is the liver's immune function primarily categorized?

    <p>A buffer between the gut and the rest of the body</p> Signup and view all the answers

    What is one of the main signs of increased hepatic venous pressure gradient (HVPG) in cirrhosis?

    <p>Development of collateral circulation</p> Signup and view all the answers

    General practitioners (GPs) are most likely to be involved in the management of which liver-related issue?

    <p>Abnormal liver blood tests</p> Signup and view all the answers

    Which of the following factors differentiates patterns of cirrhosis depending on the region of the world?

    <p>Alcohol use versus chronic viral disease</p> Signup and view all the answers

    In Western countries, which of the following tumors is more likely to affect the liver?

    <p>Liver metastases</p> Signup and view all the answers

    What is the most common liver tumor globally, particularly in regions where viral hepatitis is prevalent?

    <p>Hepatocellular carcinoma</p> Signup and view all the answers

    Which of the following is a major cause of liver damage associated with metabolic syndrome, including conditions like type 2 diabetes mellitus and obesity?

    <p>Non-alcoholic fatty liver disease (NAFLD)</p> Signup and view all the answers

    Which viral infections can cause both acute and chronic liver damage?

    <p>Hepatitis B and C</p> Signup and view all the answers

    Inherited metabolic disorders such as hemochromatosis (HFE) and Wilson's disease cause liver damage by affecting which of the following?

    <p>Iron and copper metabolism</p> Signup and view all the answers

    Which of the following is NOT a cause of autoimmune-related liver damage?

    <p>Drug-induced liver injury</p> Signup and view all the answers

    Chronic biliary disease can lead to liver damage due to retained bile salts. Which condition is most likely associated with this mechanism?

    <p>Primary biliary cirrhosis</p> Signup and view all the answers

    Chronic biliary disease can lead to liver damage due to retained bile salts. Which condition is most likely associated with this mechanism?

    <p>Primary biliary cirrhosis</p> Signup and view all the answers

    Liver damage due to vascular causes may result from which of the following mechanisms?

    <p>Congestion or ischemia</p> Signup and view all the answers

    Which of the following conditions is associated with liver damage due to a deficiency of alpha-1 antitrypsin (A1AT)?

    <p>Cirrhosis</p> Signup and view all the answers

    Which of the following drugs is most likely to cause liver damage with prolonged use?

    <p>Acetaminophen (Paracetamol)</p> Signup and view all the answers

    Which of the following provides the dual blood supply to the liver?

    <p>Hepatic artery and portal vein</p> Signup and view all the answers

    The blood flowing into the liver sinusoids is separated from the hepatocytes by which of the following?

    <p>The Space of Disse</p> Signup and view all the answers

    The blood flowing into the liver sinusoids is separated from the hepatocytes by which of the following?

    <p>The Space of Disse</p> Signup and view all the answers

    Which type of cells line the liver sinusoids and play a key role in immune defense?

    <p>Kupffer cells</p> Signup and view all the answers

    Hepatic stellate cells are located in which of the following regions of the liver?

    <p>Space of Disse</p> Signup and view all the answers

    What is the primary function of hepatic stellate cells in a healthy liver?

    <p>Vitamin A storage and regulation of extracellular matrix production</p> Signup and view all the answers

    Hepatic stellate cells can become activated in liver injury and contribute to which pathological process?

    <p>Cirrhosis and fibrosis</p> Signup and view all the answers

    Which of the following accurately describes the drainage pathway of venous blood from the liver?

    <p>Hepatic vein → Inferior vena cava → Right ventricle</p> Signup and view all the answers

    What type of endothelium lines the liver sinusoids, allowing efficient exchange between blood and liver cells?

    <p>Fenestrated endothelium</p> Signup and view all the answers

    In the liver, blood flows from the portal tract through the sinusoids and drains into which structure?

    <p>Hepatic venule</p> Signup and view all the answers

    Which of the following best describes the smallest branches found in the portal tract?

    <p>Portal vein, hepatic artery, bile duct</p> Signup and view all the answers

    Which of the following statements about liver plates is correct?

    <p>They allow restricted blood flow between hepatocytes.</p> Signup and view all the answers

    In the liver acinus, where is ischemic or toxic injury most likely to be most severe?

    <p>Zone 3</p> Signup and view all the answers

    What is the primary role of bile canaliculi in liver microanatomy?

    <p>They drain bile from hepatocytes.</p> Signup and view all the answers

    Which two ducts form the common bile duct?

    <p>Cystic duct and common hepatic duct</p> Signup and view all the answers

    What percentage of individuals have the common bile duct joining with the pancreatic duct at the ampulla of Vater?

    <p>75%</p> Signup and view all the answers

    In the liver acinus model, what does each acinus refer to?

    <p>Hepatocytes and sinusoids from two adjacent lobules supplied by one portal tract</p> Signup and view all the answers

    Chronic venous congestion of the liver is most often associated with which of the following conditions?

    <p>Right heart failure</p> Signup and view all the answers

    Budd-Chiari syndrome refers to the obstruction of venous outflow from the liver. Which of the following veins is most commonly involved?

    <p>Hepatic vein</p> Signup and view all the answers

    Which condition is commonly associated with a mild elevation of liver blood tests (ALT, AST) due to passive venous congestion?

    <p>Constrictive pericarditis</p> Signup and view all the answers

    Which of the following best describes Budd-Chiari syndrome?

    <p>Obstruction to venous outflow from the liver</p> Signup and view all the answers

    Ischaemic injury to the liver, also known as 'shock liver' or 'ischaemic hepatitis,' is typically caused by:

    <p>Hypoperfusion or circulatory failure</p> Signup and view all the answers

    Which of the following conditions increases susceptibility to ischaemic liver injury?

    <p>Passive venous congestion or cirrhosis</p> Signup and view all the answers

    In ischaemic hepatitis ('shock liver'), what is typically observed in liver blood tests?

    <p>Marked elevation of ALT and AST</p> Signup and view all the answers

    Liver infarction is extremely unusual due to the dual blood supply from which two sources?

    <p>Portal vein and hepatic artery</p> Signup and view all the answers

    Which type of heart failure is most commonly associated with passive venous congestion of the liver?

    <p>Right heart failure</p> Signup and view all the answers

    What is the characteristic gross appearance of a liver affected by chronic passive venous congestion?

    <p>&quot;Nutmeg liver&quot; with congested areas around central veins</p> Signup and view all the answers

    Which of the following is a primary function of the liver in the digestive system?

    <p>Synthesis of bile salts for fat digestion</p> Signup and view all the answers

    Which fat-soluble vitamins are absorbed with the help of bile salts produced by the liver?

    <p>Vitamins A, D, E, and K</p> Signup and view all the answers

    Which of the following plasma proteins is synthesized by the liver and plays a crucial role in blood clotting?

    <p>Fibrinogen</p> Signup and view all the answers

    Which liver function involves detoxifying both endogenous and exogenous compounds?

    <p>Metabolism of toxins</p> Signup and view all the answers

    The liver serves as a buffer between the gut and the rest of the body by performing which function?

    <p>Immune functions</p> Signup and view all the answers

    Which of the following describes the liver's role in intermediary metabolism?

    <p>Storage of glycogen and fats</p> Signup and view all the answers

    Which of the following functions is performed by the liver in the fetus and infants but not in adults?

    <p>Haematopoiesis</p> Signup and view all the answers

    What role does the liver play in bile formation?

    <p>It produces bile salts for fat digestion and excretes bilirubin.</p> Signup and view all the answers

    Chronic passive venous congestion is most marked around which liver structure?

    <p>Central hepatic vein branches</p> Signup and view all the answers

    What factor primarily determines the outcome of acute liver damage?

    <p>Degree of liver damage</p> Signup and view all the answers

    If acute liver damage is transient and does not lead to acute liver failure, what is the most likely outcome?

    <p>Recovery</p> Signup and view all the answers

    Chronic liver damage is defined as liver injury persisting for how long?

    <p>More than 6 months</p> Signup and view all the answers

    Which of the following is a potential consequence of ongoing liver injury?

    <p>Cirrhosis with fibrosis</p> Signup and view all the answers

    Which pattern of liver cell death involves the death of large groups of hepatocytes?

    <p>Bridging necrosis</p> Signup and view all the answers

    Which of the following best describes apoptosis in the liver?

    <p>Single cell death</p> Signup and view all the answers

    Massive hepatic necrosis refers to which type of liver injury?

    <p>Widespread death of hepatocytes</p> Signup and view all the answers

    Which of the following is an example of direct cytotoxic damage to the liver?

    <p>Drug-induced liver injury</p> Signup and view all the answers

    Which type of liver injury is characterized by hepatocytes being perceived as antigenic, often seen in autoimmune hepatitis?

    <p>Antigenic cell injury</p> Signup and view all the answers

    Damage to hepatocytes rendered antigenic by hepatitis B virus (HBV) is an example of which type of injury?

    <p>Antigenic cell injury</p> Signup and view all the answers

    Which of the following outcomes is most likely if acute liver damage is extensive?

    <p>Acute liver failure</p> Signup and view all the answers

    Which of the following conditions is indicative of chronic liver damage?

    <p>Liver disease persisting for more than 6 months</p> Signup and view all the answers

    Which of the following statements is true regarding the regenerative capacity of the liver?

    <p>The liver has a significant capacity for regeneration unless the damage is extensive.</p> Signup and view all the answers

    What is the primary difference between acute and chronic liver damage?

    <p>Chronic damage involves prolonged injury lasting over 6 months, while acute damage is short-term.</p> Signup and view all the answers

    What is the potential consequence of liver fibrosis progressing without intervention?

    <p>Cirrhosis</p> Signup and view all the answers

    What role does the ATP7B gene play in Wilson's disease?

    <p>It codes for a protein that helps in copper transport.</p> Signup and view all the answers

    What is the primary cause of Primary Biliary Cholangitis as indicated by the presence of Antimitochondrial Antibody (AMA)?

    <p>Autoimmune response</p> Signup and view all the answers

    Study Notes

    Overview Of Liver Disease

    • Liver disease is an increasing cause of morbidity and mortality, contributing to lost life years.
    • While less common than heart disease, cancer, and stroke, it is still a significant health issue.
    • Liver disease is managed by gastroenterologists, some specialize as hepatologists.
    • Surgeons handle cases of gallstones, pancreatitis, and sometimes extrahepatic biliary tract disease.
    • General Practitioners (GPs) typically manage abnormal liver blood tests.
    • The patterns of liver disease vary depending on the geographical location.
    • Cirrhosis can be caused by alcohol or chronic viral diseases like Hepatitis B (HBV).
    • Liver tumors can be metastases from other cancers, such as pancreatic cancer, or primary hepatocellular carcinoma.

    Causes Of Liver Damage

    • Alcohol consumption can lead to liver damage.
    • Non-alcoholic fatty liver disease (NAFLD) is often associated with metabolic syndrome, including type 2 diabetes and obesity.
    • Viral infections, including Hepatitis A, B, C, and E, can cause acute or chronic liver disease.
    • Certain medications can damage the liver.
    • Autoimmune disorders can affect the liver.
    • Inherited metabolic disorders, such as hemochromatosis (HFE gene), Wilson's disease, and alpha-1 antitrypsin deficiency (A1AT def) are also causes.
    • Vascular conditions, such as congestion or ischemia, can impact the liver.
    • Chronic biliary disease, where retained bile salts damage the liver is another cause.

    Liver Structure

    • The liver is a large organ weighing approximately 1.5 kg.
    • It has a substantial functional reserve and a stable cell population capable of regeneration.
    • The liver has a limited repertoire of responses to acute and chronic injury.
    • Understanding the history, examination, and diagnostic tests is critical.
    • Various causes of injury can interact with each other.

    Normal Liver

    • The gross appearance of a healthy liver can be used as a comparison point.
    • The liver receives blood from two sources: the hepatic artery and the portal vein.
    • Blood flows through sinusoids, spaces separating plates of hepatocytes (liver cells).
    • Sinusoids are lined by fenestrated endothelium and macrophages (Kupffer cells).
    • The Space of Disse, located between sinusoids and hepatocytes, contains hepatic stellate cells.
    • Blood drains from the hepatic vein into the inferior vena cava (IVC), and then to the right ventricle (RV) of the heart.

    Hepatic Stellate Cells

    • These cells are located in the Space of Disse, a space between the sinusoids and hepatocytes.
    • They are responsible for storing vitamin A and producing extracellular matrix proteins, which are important for maintaining liver structure.
    • In response to liver injury, they can undergo activation, leading to increased collagen production and fibrosis.

    Liver Plates

    • Liver plates are like plates in a dishwasher. They are arranged to allow free flow of fluid.
    • The arrangement of the plates allows blood to flow effectively from the portal tract through the sinusoids to the hepatic venule.

    Liver Structure - Space of Disse

    • This is a space between the sinusoids and hepatocytes that contains hepatic stellate cells.
    • Important for liver function and for the exchange of nutrients and waste products between hepatocytes and the blood.
    • It is also a site of inflammation and fibrosis in liver disease.

    Portal Tracts

    • These are the smallest branches of the portal vein, hepatic artery, and bile duct.
    • They are located within the liver parenchyma, and a distinct interface exists between the portal tract and the surrounding liver tissue.

    Bile Drainage

    • Bile is produced by hepatocytes and secreted into canaliculi, small channels between hepatocytes.
    • These small ductules form from the canaliculi and join to form small ducts within the portal tracts.
    • The left and right hepatic ducts merge to form the common hepatic duct.
    • The common hepatic duct joins the cystic duct to form the common bile duct.
    • In about 75% of cases, the common bile duct and pancreatic duct join at the ampulla.
    • The gallbladder serves as a storage reservoir for bile.

    Liver Micro-Anatomy

    • The acinus is the preferred concept for describing the functional unit of the liver, centered around portal tracts.
    • An acinus encompasses hepatocytes and sinusoids from two adjacent lobules supplied by one portal tract.
    • The acinus helps to explain patterns of liver damage, with ischemic/toxic injury most severe in zone 3.
    • The concept of the acinus allows for a precise description of damage and fibrosis patterns.

    Vascular Injury To The Liver

    • Chronic (passive) venous congestion of the liver is often associated with right heart failure (e.g., cor pulmonale, mitral stenosis), and most prominent in cases of tricuspid incompetence and constrictive pericarditis.
    • Mild elevation of liver blood tests (ALT, AST) is seen.
    • Obstruction to venous outflow from the liver (hepatic vein/IVC) leads to Budd Chiari syndrome.
    • Liver infarction is very rare.
    • Ischemic injury to the liver ("ischemic hepatitis", "shock liver") is associated with hypoperfusion, hypotension/shock/circulatory failure.
    • Marked elevation of liver blood tests (ALT, AST) occurs.
    • Outcome depends on the underlying cause.
    • Susceptibility to ischemic injury is increased by passive venous congestion or cirrhosis.

    Normal Liver - Gross Appearance

    • For comparison, the gross appearance of a healthy liver is provided.

    Chronic Passive Venous Congestion Of Liver

    • Gross appearance: The liver exhibits a "nutmeg liver" appearance.
    • Congestion is most evident around central hepatic vein branches.

    Liver Function

    • The liver synthesizes most plasma proteins.
    • It plays a role in clotting.
    • Bile production is a key function.
    • Bile excretion removes bilirubin.
    • Bile salts are responsible for digestion of fats and fat-soluble vitamins (A, D, E, and K).
    • Detoxification of endogenous and exogenous compounds occurs.
    • The liver is involved in intermediary metabolism, altering and storing various substances.
    • It plays a role in immune function.
    • The liver acts as a buffer between the gut and the rest of the body.
    • It stores normal and abnormal substances.
    • In fetuses and infants, the liver is involved in hematopoiesis (blood cell production).

    Damage To The Liver

    Acute Liver Damage

    • The liver has a reserve and regenerative capacity.
    • Outcomes depend on the degree of damage.
    • Extensive damage can lead to acute liver failure.
    • Transient and non-life-threatening damage usually leads to recovery.
    • Ongoing or repeated insults can result in chronic damage.

    Chronic Liver Damage

    • If liver insults persist, chronic liver disease develops (defined as >6 months).
    • Fibrosis develops, with increasing severity leading to cirrhosis.
    • Different causes of liver damage can coexist, be superimposed, or potentiate each other.

    Damage To The Liver Continued

    • Different patterns of cell damage and death can occur.
    • Cell injury can be reversible or irreversible.
    • Triggers of injury can vary.
    • Damage can be direct (cytopathic/cytotoxic/ischemic) or indirect.
    • Hepatocytes can become antigenic, as seen in HBV infection.
    • Cells can be perceived as antigenic, as in autoimmune hepatitis.
    • The degree of injury can range from single cell death (apoptosis) to massive hepatic necrosis.

    Assessment Of Liver Damage

    • Inflammation and necrosis: The extent of inflammation and necrosis is graded.
    • The location of inflammation is important: portal/periportal or lobular (parenchymal).
    • Interface inflammation is known as "piecemeal necrosis."
    • The pattern of portal/periportal damage is considered.
    • The presence and type of necrosis (single cells, spotty, bridging) is evaluated.
    • The predominant inflammatory cell type is identified.
    • The type of inflammatory cell depends on the etiology, not just the duration of the disease.

    Assessment Of Liver Damage Continued

    • Fibrosis: The degree and extent of fibrosis is "staged."
    • Different types of fibrosis include:
      • Portal fibrosis
      • Periportal fibrosis
      • Bridging fibrosis
      • Cirrhosis
    • Liver biopsy involves complex scoring systems to assess grade and stage independently.

    Stages Of Liver Fibrosis: Trichrome Stain

    • Fibrous tissue appears blue due to the trichrome stain.

    Definition Of Cirrhosis

    • Cirrhosis is characterized by diffuse distortion of the liver architecture.
    • Fibrous bands/septa surround regenerative nodules.
    • Vascular relationships are distorted.
    • Portal hypertension develops as a consequence of cirrhosis.
    • The functional capacity of the liver is reduced.
    • An increased risk of hepatocellular carcinoma exists.

    Cirrhosis

    • Cirrhosis is the end-stage of chronic liver disease, resulting from ongoing damage.
    • The liver's reserve is diminished.
    • Vascular changes associated with cirrhosis: - Obliteration/thrombosis of veins within the liver - Formation of collateral channels/shunts within the liver - Sinusoids become "capillarised" (lose fenestrations) - Hepatic venous pressure gradient (HVPG) rises

    Cirrhosis: Gross (Macroscopic) Appearance

    • The gross appearance of a cirrhotic liver is provided.

    Normal Liver: Histology For Comparison

    • Normal liver histology is shown for comparison, using hematoxylin and eosin (H&E) staining.

    Cirrhosis: Histology, H&E

    • Diffuse architectural distortion, regenerative parenchyma nodules separated by fibrous bands.

    Cirrhosis: Trichrome Stain

    • The trichrome stain highlights fibrous tissue in blue.

    Portal Hypertension In Cirrhosis

    • Increased resistance to portal blood flow in the liver leads to rising HVPG.
    • Increased splanchnic vasodilation (via.NO), increasing portal blood flow, contributes to portal hypertension.
    • Splanchnic vasodilation lowers total peripheral resistance (TPR) and blood pressure.
    • A compensatory increase in cardiac output leads to a hyperdynamic circulation in cirrhosis.
    • Splanchnic vasodilation triggers compensatory mechanisms.

    Portal Hypertension In Cirrhosis: Simplified

    • Increased blood supply to the intestines due to splanchnic vasodilation.
    • More blood enters the intestines, causing increased pressure in the portal system.
    • The blocked liver in cirrhosis restricts blood flow, further increasing pressure in the portal system.

    Portal Hypertension, Ascites, And HRS

    • Compensation for widespread vasodilation involves activation of the renin-angiotensin-aldosterone system and stimulation of ADH secretion.
    • Sodium and water retention occurs.
    • Reflex renal vasoconstriction reduces perfusion and glomerular filtration rate, increasing the risk of hepatorenal syndrome (HRS).

    Portal Hypertension, Ascites, And HRS Continued

    • Ascites:
      • Sodium and water retention occur in the setting of portal hypertension.
      • Fluid preferentially accumulates in the peritoneal cavity.
      • Fluid leakage from peritoneal vessels occurs.
      • Higher mean hydrostatic pressure due to portal hypertension.
      • Lower oncotic pressure to keep fluid in, due to low albumin levels.

    Portal Hypertension & Shunts

    • Attempts to decompress portal hypertension lead to the development of collaterals:
      • Intrahepatic porto-systemic shunts/collaterals
      • Extrahepatic porto-systemic anastomoses dilate
      • Therapeutic insertion of a transjugular intrahepatic porto-systemic shunt (TIPS)
    • "Shunted" blood bypasses the liver, reducing liver function (increasing HE risk), exacerbating sinusoid "capillarisation", and decreasing liver perfusion.

    Compensated Versus Decompensated Cirrhosis

    Compensated Cirrhosis

    • May or may not have biochemical/radiological abnormalities.
    • May or may not have signs of chronic liver disease/portal hypertension.
    • May or may not have varices on OGD (gastroscopy).
    • Can be a potentially unstable state, as further injury may trigger decompensation.
    • Factors that can precipitate decompensation: infection, bleeding, hypotension, alcohol, medication, dehydration, trauma, surgery.

    Compensated Versus Decompensated Cirrhosis Continued

    Decompensated Cirrhosis

    • Development of key complications:
      • Ascites (may become refractory to treatment)
      • Hepatic encephalopathy
      • Variceal hemorrhage
      • Hepatorenal syndrome (HRS)
      • Jaundice
      • Infection (esp. spontaneous bacterial peritonitis)
      • Hepatocellular carcinoma

    Compensated Versus Decompensated Cirrhosis Continued

    • Prognosis is significantly impacted by decompensation:
      • 1-year mortality for compensated cirrhosis is 1%.
      • 1-year mortality for compensated cirrhosis with varices is 4%.
      • 1-year mortality for decompensated cirrhosis with ascites is 20%.
      • 1-year mortality for decompensated cirrhosis with other features is greater than 50%.

    Decompensation Affects Prognosis

    • A visual representation of the progression of chronic liver disease and the impact of decompensation on survival.

    Natural History Of Chronic Liver Disease: Summary

    • A graphic showing probability of survival based on cirrhosis stage.

    Changing Concepts Of Cirrhosis: New

    • Progression of cirrhosis is not inevitable, and treatment can induce regression of structural changes.
    • Fibrosis is dynamic, and ongoing damage can be modified.
    • The etiology is crucial for management.
    • Active management is essential for early diagnosis, limiting progression, and preventing complications.
    • "Advanced stage of chronic liver disease" should include advanced fibrosis and potentially replace the term "cirrhosis."
    • Decompensation, when HVPG reaches a critical threshold, becomes the inevitable end stage.

    Presentation Of Liver Disease

    • Patients can be asymptomatic or experience mild nonspecific symptoms, or have an at-risk history.
    • Liver disease might be identified through liver blood tests or imaging studies.
    • Symptoms or signs that can indicate liver disease (e.g., jaundice) can be present:
      • Acute liver disease (short of acute liver failure)
      • Acute flare or exacerbation of chronic disease
      • End-stage chronic liver disease (cirrhosis)
    • Acute liver failure may occur.
    • Decompensation of cirrhosis can manifest with major complications.

    End Of Lecture

    • A question about the identification and interpretation of a specific liver case.

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