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home - Liver - Vascular Problems - Congestive Hepatopathy Written by Dr Sebastian Zeki
Knowledge


Understands the risk of variceal bleeding as a complication of with
portal hypertension


Knows risk of variceal haemorrhage in cirrhotics who have not bled

Knows risk of bleeding related to variceal size endoscopic findings
and severity of liver dysfunction


Knows range of therapeutic options (both endoscopic and
pharmacological).

Skills
Recognises and can treat portal hypertension.
Behaviours
Manages patients with oesophageal varices with skill and
compassion

Able to convey the serious risks to patients and their relatives.

Also...

Knowledge


Recognises and shows understanding of vascular liver disease
including Budd-Chiari syndrome veno-occlusive disease and
portomesenteric venous thrombosis; understands the underlying
anatomy and physiology of these often complex conditions

Aware of need for investigation for associated myeloproliferative and
procoagulant conditions

Understands the role of anticoagulation and indications for further
intervention including TIPS surgery or transplantation

Skills
Can make careful clinical of these conditions and has
heightened awareness of liver vascular disease in differential
diagnosis

Able to make a potentially difficult diagnosis of less common variants
of vascular conditions

Behaviours
Shows ability to keep patient and relatives informed and to refer
appropriately for specialist management

Congestive Hepatopathy

zone 3 acinus Z o n e 2 a c i n u s zone 3 acinus Z o n e 2 a c i n u s zone 3 acinus Z o n e 2 a c i n u s Written by Dr Sebastian Zeki Microscopic features:Sinusoidal engorgement.Degeneration and variable degrees of hemorrhagic necro-sis in the zone 3 of hepatic acinus.Fatty change.Cholestasis with some bile thrombi in the canaliculi esp if severe jaundice. Eventually causing fibrous bands to extend outward from the central veins, occasionally linking with portal tracts to produce a lesion called cardiac sclerosis that resembles micromodular cirrhosis. Reticulin and collagen accumulate in zone 3... Congestive hepatopathy PethologyMacroscopically this shows a nutmeg liver: (red central areas (sinusoidal congestion and bleeding into atrophic regions surrounding enlarged hepatic veins) and yellow areas (either normal liver tissue or fatty liver).The liver is enlarged with prominent hepatic veins. Diagnostic features70% have a mild increase in bilirubin (correlate with right atrial pressures but not with the cardiac output).Alk phos (most) and ALT (1/3rd) are usually only mildly elevated.The ALT is higher if there is coexisting ishcaemia(ALT rise correlates with extent of zone 3 necrosis on liver biopsy specimens).The albumin is low in 40% but is usually >25.The PT is mildly elevated.Ammonia levels may occasionally be elevated- can get encephalopathy without liver disease- this may be due to heart disease itself.Serum to ascites albumin gradient is >1.1 reflecting portal hypertension.Improvement in liver biochemical tests with treatment of the underlying cardiac condition provides support for the diagnosis. Clinical Manifestations:Patients are usually asymptomatic.Jaundice possible especially if acute.RUQ pain/ ascites is possible.Hepatomegaly possible.Patients often have prominent JVP (giant v waves with tricuspid Management This involves treatment of the underlying heart disease.The prognosis is predicted by the severity of the underlying heart disease, liver disease rarely contributesIt can lead to cirrhosis if it is prolonged.Constrictive Pericarditis should be treated.The presentation and pathology is similar to Budd-Chiari syndrome.Hepatomegaly, a pulsatile liver, massive ascites, and peripheral oedema are common; jaundice is usually absent.Pericardiectomy is curative if performed early.

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