GI_Final_Session 6_Cont'd

  1. explain the pathogenesis of Cirrhosis. what are the 3 main morphologic characteristics? central processes? mechanism of fibrosis?
    • 3 main morph characteristics:
    • bridging fibrous septa--fibrosis (collagen deposition & remodeling)
    • parenchymal nodules containing hepatocytes encircled by fibrosis
    • disruption of architecture of entire liver

    • Central Processes:
    • death of hepatocytes
    • extracellular matrix deposition
    • vascular reorganization
    • *collagen deposited in space of Disse --> fibrotic septal tracts --> loss of fenestrations of sinusoidal epithelial cells (apillarization of sinusoids)

    • mechanism of fibrosis:
    • proliferation of hepatic stellate cells --> activate to fibrogenic cells
    • Kupcffer cells & lymphocytes release cytokines & chemokines that modulate expression of stellate cells (TGF-beta, MMP-2)
  2. what is asterixis? what does it indicate?
    • asterixis = hand tremor when trying to extend the wrist
    • can indicate hepatic encephalopathy
  3. describe the virology of HCV infection.
    • HCV:
    • Hepacivirus
    • enveloped, +ssRNA
    • infects liver cells & lymphocytes
    • Interrupts apoptotic signals via cytokines (TNF-a, IFNa)
  4. describe the natural hx of HCV
    Image Upload 1
  5. what is decompensated cirrhosis?
    it is the final/later stage of cirrhosis that shows:

    • asites
    • varices
    • encephalopathy
    • jaundice
  6. what factors of cirrosis contribute to creating ascites?
    Image Upload 2
  7. what is the pathogenesis of SBP?
    • protein is LOW (icluding complement proteins), usually <1g/dL is high risk for developing
    • poor liver filtration fn can allow spread of microbes
    • decreased activity of neutrophils in pt's w/ advanced liver dz
    • *poor opsonic activity -->SBP
    • *moderate --> CNNA
    • *good --> sterile nonneutrocytic ascites
  8. what dxic tests can be done to evaluate ascites & cirrhosis?
    • Ascites:
    • look for "shiftin dullness" (air-fluid interface)
    • XR - central bowel gas pattern
    • US - can schow ascites & fat/fibrosis

    • Cirrhosis:
    • Serum-Ascites Albumin Gradient >1.1g/dL suggests cirrosis
    • MRI - splenomegaly, abnL parenchyma
    • cytology to check for cancer
    • culture
    • biopsy to guide Tx
  9. what causes SBP? what are the signs and what tests need to be done?
    • SBP caused by:
    • enteric G- bacteria- E.coli (50%), Kelbsiella (10%), Strep. pneumonia & grp A streps (15-20%) or anaerobic/microaerophilic organisms (55)

    • Signs/tests:
    • ascites associated w/liver disease
    • >250 PMN's/mL of ascites fluid
    • usually have fever
  10. describe the long term management for Cirrhosis
    • evaluate for liver transplant, get on waiting list
    • while waiting:

    • --diuretics: aldosterone blocker b/c we have a 2ndary hyperaldosterone issue (spironolactone), + loop diuretic (furosemide)
    • Sodium restricted diet + fresh food, avoid processed
    • --Propranolol, metolol (non-selective beta-blockers) b/c might have inadequate venous return (lowBP) b/c of pressure on IVC from ascites
    • --therapeutic drainage - no more than 5L & replace w/fluid containing albumin
    • --pts w/cirrhosis should get HAV, HBV, pneumococcal & influenza vaccines
  11. what additional tx may need to be done if having recurrent ascites & varices in liver cirrhosis?
    • Transjugular Intrahepatic Portosystemic Shunt (TIPS); appears to be tx of choice for refractory hepatic hydrothorax
    • *complications: hepatic encephalopathy b/c can't remove nitrogenous wastes **need to give lactulose to help remove ammonia
  12. what tx needed for SBP?
    • IV cefotaxime (ceftriaxone & amoxicillin-clavulanic acid are alternatives)
    • may need supplemental administation of IV albumin
    • **in high-risk cirrhotic pt's the risk of peritonitis, hepatorenal syndrome & death may be reduced by prophylactiv norfloxacin, ciprofloxacin, or TMPS**
  13. what signs indicate hepatorenal syndrome?
    • advanced cirrhosis & ascites
    • azotemia (serum Cr >1.5mg/dL) in the absence of parenchymal kidney dz or shock & failure of kidney fn to improve
    • oliguria
    • hyponatremia
    • low urinary sodium
  14. describe pathogenesis of Esophageal Varices
    • increased portal venous pressure secondary to cirrhosis
    • systemic vasodilation w/decreased vascular resistance and the formation of a hyperdynamic circulation may also contribute
    • increased flow is responsible for 40% of increase; resistance to flow is responsible for 60% of increase in portal pressure in cirrhosis
  15. describe management of esophageal varices.
    • they MUST go to ICU
    • band ligation **preferred method
    • sclerotherapy + Rx
    • +prophylatic abiotics
  16. describe the early treatments of ascites ("dropsy").
    • squill bulb (contains cardioactive glycosides similar to digitalis)
    • mix of: white chameleon thistle, wall germander, yellow bugle, periwinkle (Pliny only used the first 2)
  17. what is the pathogenesis of a Mallory-Weiss tear?
    vertical mucosal tear of GEJ usually associated w/increased abd pressure
  18. describe the steps for evaluating an Acute Upper GI bleed.
    • Upper endoscopy = test of choice
    • early endoscopy is good for management descisions
    • Image Upload 3
  19. what is the management steps for an active UGI bleed?
    • **see algorithm
    • stabalize: IV fluid, blood if needed
    • Vasopressin to vascoconstric @ local site
    • admit to ward --> discharge when stable
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GI_Final_Session 6_Cont'd
westernu final, session6