Ja R a MD MPH

• E d age e d ea e e e be
• Re f a ca e f ch c e d ea e
• V a He a e ec a B a d C
• A c h c e d ea e
• N a c h c fa e d ea e
• Sh e e
• L e e e aced b fib i a d n d le aterpobnecomes
fostFame
• S he e face e aced b d e chronicinflammation

We c e I age
 One of the livers functions is to
processammonia convert it to
urea via the urea cycle
C ca Fea e THEREFORE
If the liver is failingfrom
cirrhosis the patient will
• H e amm nemia have hyperammonemia
• A e c f c a

flappingof the hands

when thehands are
extended
T ea e try to lower ammonia

• L e de STEAK
• Lac l e
• S he c d accha de a a e increases bowl movements
• C b ea d b bac e a fa ac d
• L e c c H fa f a f NH e NH
• NH ab bed a ed c goes out inthe stool
• Re a aa a c ce a
C ca Fea e

• Ja ndice Abilirubin in theserum

• L fb b e ab
• H gl cemia
• L fg c e ge e
• C ag l ah
• L fc g fac
• E e a ed PT PTT
• H alb minemia the liver loses
theabilityto producealbumin
Ja e He a MD
• Ma ca e c c e e
2
• C b e a c e ede a albuminin theblood is
the maindriverfor
Oncolicpressure
 cirrhosiscan impactcapillary
fluid shifts
Ca a F d Sh f
Thereare two forces that control the movement of fluid out of the capillaries into
the tissues
• Ca a h d a ic e e Pc
• D e f d f ca a e e

• Ca a nc ic e e c cirrhosis leads to a fall in

J
• P e ab ae ca a e the amount of albumin
in the serum
• Re e e ff d f ca a e z
this leads to a fall in the
oncoticpressurewhich pushes
more fluid out of the
capillary
Pc c
ascities edema
C ca Fea e

• E e a ed e gen
• N a e ed b e
2
• G ec a a e with a cirrhotic
liver it can lead
• S de a g aa to the rise in
estrogenlevels
• Pa a e he a
y
estrogenmakes
I age c e D M dca B a W ed a

skin red

SPIDER ANATOMATA
Red lesionson the
skin due to increased
number of blood
vessels below the
skin

He be L F ed MD a d He d A a D
ANNAf e
• B df a e e he a c e
• C h b c ed f h gh e
• H gh e e a e h e e

P a He a c
Ve LIVER Ve

t
Obstructedblood flowthrough
the liver will lead to A pressures
in the portal men
 VASODILATION
airnosisleads to the B in production
of manyvasodilators especially NO
Ni ic O ide
He d a c
Ab S a ch c a d a

H in systemic
O c cP e e vascular resistance SVR BP
is a hallmark of
cirrhosis
Fluid leaks out of the
capillaries Effec i e Ci c la ing S a he c
THEREFORE
V l me Ac a
the bodyresponds as if
there is low volume RAAS CO
poortissueperfusion ADH

Na H O

T al B d cirrhosis causes an A total body

water yet a fall in the effective
Wa e there is a
circulating volume
disconnection between the two
 T a B d P a to develop ascities a patient
must have portal
Wa e HTN hypertension

Edema A ci e

ab
Pa e hc h
b h a HTN
d de e a c e
 These are small bloodvessels that
are usually collapsed
Ve A a a e the become dialated when
there is high portalpressure
• H gh a e e e e c ae a
• C ec be ee a e c e
• N a a c a ed e e
• E g ge a h e e
• Ke c a e a
• Umbilic h ca e a f d g ca ed a
• E hag e ga e a b eed g
• S mach e ga e a b eed g
• Rec m he h d h ch a a b eed
 normally theyare small the pressure P
collapsed because the two HOWEVER when due to portalhypertension
Viensare draining bloodequally the collateral cars
well the pressures are too high become dialated G
normallythere are small twisted2
Viens connecting the
two hens called they lead to
anastomosis many of the
collaterals ok withportalhypertension
Haining'nintoneme Iniestacnn.EEsniEr
portalsystem can get
veryhigh

this hen is draining

this rien drains the
the systemicsystem bloodinto the portal
system
itdrains into the
we
 dialated tortious blood
f vessels

develop due toswellingof the collateral

due to portal hypertension E hagea
Ve
M e hagea tone.me
e nEfdaieracs

e d a age a two smoothiesthat

e hagea e are usually small
Lef Ga c Ve collapsed
SVC
c a e
S a a f
e fca b d
1
When the portalpressure
a ef ga c e the pressure in the left
a e gastric hen to 4

this leads to swelling of

the collateral 3 leads to
the development of
esophagealvarices
 swollen bulging
A
Viens
b Wikipedia P blic Domain
if one ruptures the patient
couldexangueriale die most people with cirrhosis
and have coaguiopathy are
I
bloodisdrained prone to bleeding
from a person
Sh ga ic ein Lef Ga c Ve
da b df c a e
ach f d
ef ga c e a d
toneme
EEIIEEEEF.mn
splenic n
e c e b h
7
ensz
a f a when the portal pressure is
S e c
e high the shortgastrichens
Ve can dialace bleed
upperCtl bleedingdue to
S e Me e e c Ve
gastric
I fe Me e e c Ve varices
 Ca Med a a
h ca e a
f d g f e g ged
e a d he
b c

round the epigastric area paraumbilical

wens drain blood into the portal
system Pa a b ca
Ve
formed due

i
epigastrichens
E ga c
Ve
Epigastrichens drain
blood into the WC
In e nal hem h id
ab e de a e e
cc a HTN

they can become swollen

in patients with portal
hypertensioncausing
hemorrhoidalbleeding

EFaYs
im
S e Rec a
Ve
2collateral
M dd e I fe
Rec a Ve
2
drain into the
IVC
E g ge e f he
ee a HTN
ead l la ele

S e c
Ve
2
drains the spleen
into the portal
system
 leads to the development of portal hypertension without cirrhosis Of the linen
• Ra e ca e f a h e e
• Ac e e abd minal ain
• S e ega al able leen e e a
• Ma e ga c a ce h bleeding
• L e b be a
• Acc a ff d e i neal ca i
• I e d ea e f a h e e
ab drives fluid out of the plasma
into the peritoneal cavity
low albumin to the Ahydrostaticpressure
oncoricpressures
favours the
movement of
fluid into the
peritonealcavity
The abdomen is distended
tense

Ja e He a MD W ed a
 Test todetermine whether ascites
is due to portalhypertension
Se A c e Ab G ad e

• Te fa c cf d
• T ea f e e ga c e
• P a h e e
• Ma g a c ea a c a e
• Sa e f a c c f d a a ace e
• Se ab a c e ab SAAG
Gascinesalbumin conc is compared to albumin conc in the serum
Se A c e Ab G ad e

• SAAG g dL HIGH
• La ge d ffe e ce be ee e a da c e ab
• H gh e ed gf d ab e e
• See al h e en i n BUT the vasculature is intact
albumin remains in the serum
more common cause
• SAAG g dL LOW
• Ab e e a be ee e a da c e
• Lea a c a e ead g f d a b e e
• See a g a a c e a g a ce e ea ca
 we want to remove fluid from body
similar to when it is caused due to HF
• S d e c
• S i n lac ne d g f ch ce diuretics
• P a a gd e c
• B c ad e ed a b e
• M effec ed gf a c e
• L d e c d e e.g furosemide
• La ge e a acen e i 2
removal of fluid
• TIPS via drainage
surgicalprocedure

Ja e He a MD W ed a
Ta g a I ahe a c P e c Sh

• T ea e f a h e e
• C ea f cha e e
• C ec a e he a c e

high pressure
due to cirrhosis
of the liver
stent is placed to
ensure the channel
remains Open
Channel is creates
to allow flow R T a ce A d e MD
between the two
wens
this will reduce the
pressure in the portal hen
complication of ascienes z

S a e Bac e a Pe

• A c c f d fec
• Bac e a g ga e a c cf d
• U a E c li and Kleb iella a e e a h
• Fe e abd gram negatives
a a e de e
• a c c ab e PMN ce
• C ea e
• d ge e a ce ha cef a e
• Ga ea dg a ega e c e age
• Ach e e g d e e a c cf d
M de F E d S age L e D ea e

• Sc ing em f ch c e d ea e c h
• E ae h a f e d ea e
• P e g
• B b e e When these become abnormal it
means the liver is failing at its
• C ea e e e job in metabolising bilirubin
synthesising coagulationfactors
• INR
2
• a Other factors such as ALT G AST are
• a wet port of the scoring system
they do Not predict mortality well
as they are a good indication of
inflammation BIT do not tell US
how well the liver is functioning
• F e a ab e ed c a
• P f e ce ha ah a c e b b ab PT
• Sc e a ge f
• Ch d P gh c a A c h
• Ch d P gh c a B c h
• Ch d P gh c a C c h
D ag

• G d a da d li e bi Patients with cirrhosis

• N e ed f d ag c ea f h
fE 9595978n'is
• D e he b cha ge a age e taking a biopsy

• I ag g a d CT MRI
• Ma h mall n d la li e
• N e e ec f c f d ag
• M e he f f de ec f he a ce a ca c a
2
• C ca d ag c patients with chronic
• P e e ce f a c e liver disease are at
risk this cancer
for
• L a ee c
• S de a g aa
 we
won
t play a major role in
the development of cirrhosis

• Pe da ce found on the
the sinusoids
sides of
channels between the portal hen
the central
• S age e f e d a A e ab e Vien

• Ac a ed e d ea e
• Sec e e TGF
• P fe a e a d d ce f b e
• Ma c b c h

F e e U E ge a S Z gb d S S a ge J Ng B e a