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Complications of Cirrhosis

Electrolyte Imbalance in Cirrhosis

  • Metabolic Alkalosis and Hypokalemia
    • Associated with secondary hyperaldosteronism
  • Diarrhea
    • May be due to malabsorption secondary to splanchnic venous hypertension
  • Deleterious Effects of Metabolic Alkalosis
    • ODC (Oxygen Dissociation Curve): Shift to the left β†’ impaired tissue oxygen delivery
    • Ammonium chloride β†’ ammonia β†’ encephalopathy

Ascites:

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Management of Cirrhosis and Ascites

  • First-line Treatment
    • Sodium restriction: 88 mmol/day (2000 mg/day)
    • Diuretics:
      • Oral spironolactone
      • +/- Oral furosemide
  • Fluid Restriction
    • Not necessary unless serum sodium is less than 120-125 mmol/L

Refractory Ascites

  • Definition
    • Fluid overload that:
      • Is unresponsive to sodium-restricted diet and high-dose diuretic treatment (400 mg/day spironolactone and 160 mg/day furosemide)
      • Recurs rapidly after therapeutic paracentesis
  • Management Options
    • TIPS (Transjugular Intrahepatic Portosystemic Shunt)
    • Shunt procedures
    • LTP (Liver Transplantation)

Hepatic Encephalopathy

  • Ammonia Production
    • Ammonia is produced when intestinal bacteria break down blood in the GIT.
    • Neurotransmitters (NTs) are altered in the CNS.
  • Management Strategies
    • Control active bleeding and reduce dietary protein to minimize ingested blood.
    • Glucose in the diet inhibits ammonia production by bacteria.
    • Lactulose
      • Acts as a mild cathartic.
      • Its breakdown products interfere with ammonia transfer across the colonic mucosa.
    • Rifaximin
      • Changes bacterial flora.
    • L-ornithine, L-aspartate
      • Converts to favorable amino acids.

Hepatorenal Syndrome (HRS) - Criteria

  • Cirrhosis with ascites and Serum Creatinine β‰₯ 1.5 mg/dL
  • No improvement of serum creatinine after at least 2 days with:
    • Diuretic withdrawal
    • Volume expansion with albumin (1 g/kg/day, up to a maximum of 100 g/day)
  • Absence of shock
  • No current or recent treatment with nephrotoxic drugs
  • Absence of parenchymal kidney disease evidenced by:
    • Proteinuria ≀ 500 mg/day
    • Microhematuria (≀ 50 RBC/hpf)
    • Abnormal renal USG

Types of HRS

  • Type I HRS
    • Rapidly progressive reduction in renal function.
    • Doubling of initial serum creatinine to a level β‰₯ 2.5 mg/dL or
    • 50% reduction of the initial 24-hour creatinine clearance to a level ≀ 20 mL/min within less than 2 weeks.
  • Type II HRS
    • Does not have a rapidly progressive course.
    • Common cause of death in patients who do not succumb to other complications of cirrhosis.

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Pulmonary Syndromes Associated with Cirrhosis

  • Hepatopulmonary Syndrome (HPS)
    • Pathophysiology: Long-standing cirrhosis β†’ Intrapulmonary vascular dilatation and hypoxemia.
    • Clinical Features (C/F):
      • Orthodexia (worsening oxygenation when standing)
      • Platypnea (shortness of breath relieved by lying down)
    • Investigation of Choice (IOC): Contrast ECHO
  • Portopulmonary Hypertension (POPH)
    • Pathophysiology: Pulmonary hypertension due to Pulmonary Vasoconstriction from portal hypertension.
    • Pulmonary artery pressure will be > 25 mmHg.
    • Clinical Features (C/F): Cardiac Arrhythmias
  • Management
    • Liver Transplant (TOC): Treatment of choice for both HPS and POPH.
    • Contraindication: Portopulmonary Hypertension with Pressure > 50 mmHg is a contraindication for liver transplant.

Spontaneous Bacterial Peritonitis (SBP)

  • Definition:
    • Spontaneous bacterial infection of cirrhotic ascites without suppurative infection or bowel perforation.
    • SBP is a common and serious complication of cirrhotic ascites with prevalence ranging from 10% to 27% at the time of hospitalization.
  • Clinical Significance:
    • SBP is a potentially lethal complication and a marker of decreased survival.
    • Historically, first episodes of SBP had a mortality rate of 47%.
    • Renal failure plays a significant role in both immediate and late mortality.
  • Pathophysiology:
    • Bacterial translocation is key, commonly involving enteric gram-negative aerobic bacteria.
    • Recent trends show more gram-positive bacteria and quinolone-resistant bacteria due to increased antibiotic use.
  • Host Factors:
    • Cirrhotic patients are uniquely susceptible due to decreased reticuloendothelial function, leukocyte function, and diminished opsonic activity of ascitic fluid.
    • Low ascitic fluid protein (< 10 g/L) correlates with a higher risk of SBP.
  • Symptoms:
    • Varied and subtle symptoms, including fever, abdominal pain, acute kidney injury, hepatic encephalopathy, and jaundice.
    • GI bleeding can both promote bacterial translocation and increase SBP risk.
    • Prophylactic antibiotics during variceal bleeding reduce rebleeding risk.
  • Diagnosis:
    • Perform paracentesis in all patients with new-onset ascites or clinical deterioration.
    • Diagnostic Criteria:
      • Neutrophil count > 250 PMN cells/ΞΌL in ascitic fluid.
      • Positive culture from ascitic fluid.
    • CNNA (Culture-Negative Neutrocytic Ascites) has similar management and prognosis as SBP.
    • Bacterascites refers to positive culture with normal neutrophil count; often transient.
  • Distinguishing from Secondary Peritonitis:
    • Consider secondary peritonitis if:
      • Glucose < 50 mg/dL
      • Ascites protein > 1 g/dL
      • Ascites LDH > serum LDH
  • Treatment:
    • Empirical antibiotics promptly after diagnosis:
      • Third-generation cephalosporins (e.g., cefotaxime, ceftriaxone) are first-line.
      • Five days of therapy is generally sufficient.
    • Albumin infusion to prevent acute kidney injury:
      • Dosage: 1.5 g/kg at diagnosis, 1 g/kg on day 3.
      • Reduces renal impairment from 33% to 10% and hospital mortality from 29% to 10%.
      • Especially beneficial in patients with pre-existing kidney disease and serum bilirubin > 4 mg/dL.
  • Prophylaxis:
    • Recommended for patients with prior SBP episodes or ascites protein < 10 g/L.
    • Concerns exist regarding long-term antibiotic use and antibiotic-resistant organisms.

MCQ’s

MCQ: Porto Pulmonary Hypertension in Cirrhosis

Question: All are true statements regarding Portopulmonary hypertension in cirrhosis EXCEPT:

a) Echocardiography is used for screening

b) Pulmonary artery catheterization is required for confirmation of diagnosis

c) Its presence is a contraindication for liver transplantation

d) Prostanoid therapy is useful

Correct Answer: c) Its presence is a contraindication for liver transplantation

Explanation:

  • Echocardiography is indeed used as a screening tool for Portopulmonary hypertension.
  • Pulmonary artery catheterization is required for confirmation of the diagnosis.
  • Mild degrees of pulmonary artery hypertension (up to 35 mmHg) do not preclude liver transplantation in otherwise acceptable candidates. However, pressures greater than 35 mmHg require aggressive evaluation and treatment.
  • Prostanoid therapy is useful in managing Portopulmonary hypertension.

Therefore, presence of Portopulmonary hypertension itself is not an absolute contraindication for liver transplantation unless the pulmonary artery pressure exceeds 50 mmHg.

MCQ: Most Effective Diuretic for the Management of Ascites in Cirrhosis

Question: Most effective diuretic for the management of ascites in cirrhosis:

a) Spironolactone

b) Furosemide

c) Thiazide

d) Amiloride

Correct Answer: a) Spironolactone

Explanation:

  • Spironolactone is a potassium-sparing diuretic that acts as an aldosterone antagonist. It is considered the most effective diuretic for managing ascites in cirrhosis due to its ability to counteract the effects of secondary hyperaldosteronism, which is common in these patients.
  • Furosemide is often used in combination with spironolactone, but it is less effective when used alone for ascites.
  • Thiazide diuretics and Amiloride are not as effective as spironolactone in this context.

MCQ: Best Choice of Treatment for Recurrent Variceal Bleed and Ascites

Question: JIPMER DEC 2018: Best choice of treatment for recurrent variceal bleed and ascites:

a) SSPCS (Selective Shunt Procedure: Selective Splenorenal Shunt)

b) Devascularization

c) DSRS (Distal Splenorenal Shunt)

d) TIPS (Transjugular Intrahepatic Portosystemic Shunt)

Correct Answer: a) SSPCS

Explanation:

  • SSPCS (Selective Splenorenal Shunt) is considered the best choice for the treatment of recurrent variceal bleeding and ascites because it selectively decompresses the gastroesophageal varices while preserving portal perfusion, reducing the risk of hepatic encephalopathy compared to non-selective shunts.
  • Devascularization is usually reserved for patients who cannot undergo shunt procedures.
  • DSRS (Distal Splenorenal Shunt) is another selective shunt but is typically used for patients without significant ascites.
  • TIPS (Transjugular Intrahepatic Portosystemic Shunt) is commonly used, but SSPCS may be preferred in cases where long-term management is needed without increasing the risk of hepatic encephalopathy.

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MCQ: Management of Refractory Ascites

Question: Not true regarding the management of refractory ascites?

a) TIPS can be done as a bridge to LTP

b) DSRS helps in retaining splenic activity in those with refractory ascites without hypersplenism

c) Mesocaval shunt or PSRS are usual shunts done if liver function is relatively maintained

d) Peritoneo venous shunts do not help in long-term management due to frequent blockage

Correct Answer: b) DSRS helps in retaining splenic activity in those with refractory ascites without hypersplenism

Explanation:

  • TIPS (Transjugular Intrahepatic Portosystemic Shunt) can indeed be done as a bridge to liver transplantation (LTP), especially in patients with refractory ascites.
  • DSRS (Distal Splenorenal Shunt) is primarily used to manage portal hypertension and variceal bleeding; it is not specifically beneficial in patients with refractory ascites without hypersplenism, and its use in such cases is not standard.
  • Mesocaval shunt or PSRS (Proximal Splenorenal Shunt) are common shunts performed if liver function is relatively well-preserved.
  • Peritoneo venous shunts are associated with frequent blockage, making them less useful for long-term management.

MCQ: Spontaneous Bacterial Peritonitis (SBP)

Question: Which is true regarding Spontaneous Bacterial Peritonitis?

a) Ascitic fluid protein content > 10 g/L promotes SBP

b) Prophylactic antibiotic is recommended in the above set of patients

c) Albumin infusion prevents renal dysfunction in patients with SBP, particularly in those with bilirubin > 4 mg/dL

d) Renal dysfunction occurs in 10% of those with SBP

Correct Answer: c) Albumin infusion prevents renal dysfunction in patients with SBP, particularly in those with bilirubin > 4 mg/dL

Explanation:

  • Ascitic fluid protein content < 10 g/L (not > 10 g/L) is associated with a higher risk of developing SBP, so option a) is incorrect.
  • Prophylactic antibiotics are recommended in patients with low ascitic fluid protein (< 10 g/L), but this does not directly relate to option b) as stated.
  • Albumin infusion has been shown to prevent renal dysfunction in patients with SBP, especially in those with serum bilirubin > 4 mg/dL or serum creatinine > 1 mg/dL, making option c) correct.
  • Renal dysfunction occurs in a higher percentage of patients with SBP, typically around 30-40%, not just 10%, so option d) is incorrect.

Thus, the correct answer is c) Albumin infusion prevents renal dysfunction in patients with SBP, particularly in those with bilirubin > 4 mg/dL.

MCQ: Appropriate Maneuvers in Hepatic Encephalopathy

Question: Appropriate maneuvers in a patient with hepatic encephalopathy include all of the following EXCEPT:

a) Addition of glucose to the diet

b) Administration of lactulose

c) Construction of a side-to-side portacaval shunt

d) Limiting dietary protein

Correct Answer: c) Construction of a side-to-side portacaval shunt

Explanation:

  • Addition of glucose to the diet helps in reducing ammonia production by intestinal bacteria, which is beneficial in managing hepatic encephalopathy.
  • Administration of lactulose is a standard treatment for hepatic encephalopathy as it acts as a cathartic and reduces ammonia absorption in the gut.
  • Limiting dietary protein is recommended to decrease the production of ammonia, which exacerbates hepatic encephalopathy.
  • Construction of a side-to-side portacaval shunt is generally not recommended in patients with hepatic encephalopathy as it can worsen the condition by increasing the diversion of blood away from the liver, thus elevating ammonia levels in the blood.

MCQ: Hepatorenal Syndrome (HRS)

Question: False regarding HRS?

a) Albumin infusion in addition to antibiotic therapy in SBP patients prevents development of HRS

b) Type II HRS β€” mortality rate very high in spite of treatment

c) Albumin and terlipressin are recommended drugs in HRS

d) Dialysis-dependent HRS with creatinine clearance < 30 mL/min for more than 2 weeks is an indication for combined liver and kidney transplant

Correct Answer: b) Type II HRS β€” mortality rate very high in spite of treatment

Explanation:

  • Albumin infusion combined with antibiotic therapy in SBP patients is known to prevent the development of HRS (option a is correct).
  • Type I HRS has a high mortality rate despite treatment, whereas Type II HRS typically has a slower progression and a lower mortality rate than Type I. Therefore, the statement in option b is false.
  • Albumin and terlipressin are indeed the recommended drugs for managing HRS (option c is correct).
  • Dialysis-dependent HRS with creatinine clearance < 30 mL/min for more than 2 weeks is an indication for combined liver and kidney transplantation (option d is correct).

MCQ: Non-Hepatic Surgery in Cirrhosis

Question: Which statement is False regarding non-hepatic surgery in cirrhosis?

a) CTP А & B, MELD < 15 - safe cholecystectomy

b) Morbidity rate for CTP A, B & C - 20%, 60%, and 80% respectively

c) Elective umbilical hernia repair with mesh is preferred in compensated cirrhosis

d) Gastric banding is recommended bariatric procedure in cirrhotics

Correct Answer: d) Gastric banding is recommended bariatric procedure in cirrhotics

Explanation:

  • CTP (Child-Turcotte-Pugh) A & B and MELD < 15 are considered safe criteria for performing cholecystectomy in cirrhotic patients, making option a correct.
  • The morbidity rates for non-hepatic surgery in cirrhotic patients increase with the severity of liver disease: 20% for CTP A, 60% for CTP B, and 80% for CTP C, so option b is correct.
  • Elective umbilical hernia repair with mesh is preferred in compensated cirrhosis, as it has a lower risk of complications, so option c is correct.
  • Gastric banding is not recommended as a bariatric procedure in cirrhotic patients. Instead, sleeve gastrectomy is preferred due to better outcomes and fewer complications in these patients, making option d the false statement.

Therefore, the false statement is option d).

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MCQ: Most Common Acid-Base Disturbance in Cirrhosis and Portal Hypertension

Question: Which of the following is the most common acid-base disturbance in patients with cirrhosis and portal hypertension?

a) Metabolic acidosis

b) Respiratory alkalosis

c) Metabolic alkalosis

d) Respiratory acidosis

Correct Answer: c) Metabolic alkalosis

Explanation:

  • Metabolic alkalosis is the most common acid-base disturbance in patients with cirrhosis and portal hypertension. This is primarily due to factors like secondary hyperaldosteronism, diuretic therapy, and hypokalemia.
  • Respiratory alkalosis is also common in cirrhosis due to hyperventilation, but it is not the most common disturbance in the context of portal hypertension.
  • Metabolic acidosis and Respiratory acidosis are less common in this setting.

Thus, Metabolic alkalosis is the correct answer as the most common acid-base disturbance in these patients.