|
Snapshot
  • A 65-year-old male with a long history of alcohol abuse presents to an emergency room with a painful hemorrhoid. You note severe ascites on exam.

Introduction
  • Irreversible liver damage resulting in fibrosis
    • hepatocytes regenerate forming nodules but have abnormal architecture
    • there are 2 types of nodules
      • micronodular
        • nodules < 3 mm, uniform size
        • follows metabolic insult
      • macronodular
        • nodules > 3 mm, varied size
        • hepatic necrosis
        • ↑ risk of hepatocellular carcinoma
    • nodules increase vessel pressure in the sinusoids
    • results in congestion of the portal vein
  • Causes
    • similar etiologies to hepatitis
    • alcohol (micronodular) 
      • most common cause in the United States.
    • metabolic (micronodular)
      • Wilson's
      • hemochromatosis
    • chronic viral hepatitis  (macronodular)
      • results in a specific "post-necrotic" cirrhosis
    • drug-induced (macronodular)
    • autoimmune
      • primary biliary cirrhosis
      • autoimmune hepatitis
  • Both lead to an increased risk of hepatocellular carcinoma
Presentation
  • Physical exam
    • caused by two main disease processes
      • hepatic failure
        • palmar erythema
        • Dupuytren's contracture
        • encephalopathy
          • ↓ excretion of ammonia
          • worse in alkalemic states
            • NH3 favored over NH4+
        • jaundice
          • ↓ excretion of billirubin
        • pitting ankle edema
          • ↓ synthesis synthesis of albumin
        • gynecomastia/spider angiomas/female hair distribution
          • ↓ degradation of estrogens
        • bleeding (↑ PT)
          • ↓ synthesis of coagulation factors
        • asterix
          • "flapping" tremor
      • portal hypertension
        • hepatosplenomegaly
          • splenomegaly is secondary to portal hypertension
        • caput medusae
        • ascites
          • also due to hypoalbuminemia, secondary hyperaldosteronism

Evaluation
  • Elevated AST and ALT
    • AST:ALT > 2 suggests alcoholic hepatitis
      • other liver pathologies have ALT > AST
      • inversed because AST is found in the mitochondria and EtOH is a mitochondiral toxin
  • Absolute neutrophilic leukocytosis
    • seen in hepatitis but not fatty change
  • Fasting hypoglycemia
  • Increased anion gap metabolic acidosis
  • Hypertriglyceridemia
  • Hyperuricemia
  • Thrombocytopenia
  • Increased γ-gluamyltransferase
    • secondary to EtOH induced hyperplasia of the smooth ER
Treatment
  • Surgical
    • liver transplant
    • portal shunting
      • portacaval
        • portal → hepatic vein
      • mesocaval
        • SMV → vena cava
      • splenorenal
        • splenic vein→ renal vein
      • transjugular intrahepatic portosystemic
        • portal → hepatic vein
Prognosis, Prevention, and Complications
  •  Complications of portal hypertension
    • esophageal varices
      • may rupture resulting in massive hematemesis
    • hemorrhoids
    • spontaneous bacterial peritonitis 
 

Please rate topic.

Average 3.0 of 2 Ratings

Questions (3)
EVIDENCE & REFERENCES (3)
Topic COMMENTS (14)
Private Note