A 53-year-old man who has not seen a physician in years presents to your office complaining of abdominal distention. He states "Last month my stomach started to swell up and it hasn't gotten any better". He has no other medical problems. The patient admits to drinking 10-12 beers a day for the last 20 years. His temperature is 36.7 C (98 F), blood pressure is 116/72 mm Hg, pulse is 78/min and respirations are 20/min. On examination his abdomen is distended with engorged paraumbilical veins. There is also palmar erythema and multiple spider angiomas are present. You decided to place him on a low-salt diet and start therapy with furosemide and spironolactone, with subsequent improvement of his abdominal distention. Before beginning this patient's treatment, which of the following structures labeled on the image below is expected to have an increased pressure?

Question

A 53-year-old man who has not seen a physician in years presents to your office complaining of abdominal distention.  He states "Last month my stomach started to swell up and it hasn't gotten any better".  He has no other medical problems.  The patient admits to drinking 10-12 beers a day for the last 20 years.  His temperature is 36.7 C (98 F), blood pressure is 116/72 mm Hg, pulse is 78/min and respirations are 20/min.  On examination his abdomen is distended with engorged paraumbilical veins.  There is also palmar erythema and multiple spider angiomas are present.  You decided to place him on a low-salt diet and start therapy with furosemide and spironolactone, with subsequent improvement of his abdominal distention.  Before beginning this patient's treatment, which of the following structures labeled on the image below is expected to have an increased pressure?

Quizplus · Accepted Answer

11ec160b_358b_84bd_9249_9d77d108b5cd_MD0001_00 The patient described in the question stem is likely suffering from alcohol-induced cirrhosis, a form of micronodular cirrhosis associated with hepatocyte death followed by fine fibrosis of the liver. As cirrhosis worsens and the number of functioning hepatocytes decreases, the functional ability of the liver diminishes. In advanced disease, portal blood has an increasingly difficult time passing through the liver because the vasculature becomes compromised by the progressive fibrosis, causing portal hypertension. Of the structures identified on the image above, only the portal and splenic veins are part of the portal venous system. In this patient, high pressure would be expected throughout the portal system, including the superior mesenteric, portal, and splenic veins. The effects of prolonged portal hypertension include varices at the four sites of portocaval anastomoses (esophagus, rectum, umbilicus, and retroperitoneal), as well as ascites. The pathogenesis of ascites in patients with cirrhosis is complex. In addition to mechanical compromise of portal vein flow by fibrotic tissue, vasoactive agents also play a role by causing dilatation of the splanchnic arterial vasculature and further intrahepatic vasoconstriction. These processes result in increased portal vein hydrostatic pressure leading to ascitic fluid formation, as well as decreased systemic perfusion pressure. The kidney senses the decreased perfusion pressure (accentuated by renal vasoconstriction in hepatorenal syndrome) and responds with avid retention of sodium and water, thus promoting further increase in ascitic fluid formation. Treatment of ascites secondary to cirrhosis involves restriction of sodium intake combined with diuretics. The most commonly prescribed initial therapy is a combination of furosemide and spironolactone. (Choice A) The descending abdominal aorta will have elevated pressures in patients with systemic hypertension. (Choice B) The inferior vena cava experiences increased pressure in cases of heart failure. This patient does not present with the typical symptoms associated with heart failure, such as lower extremity edema and shortness of breath. (Choice D) The celiac trunk emerges from the aorta at this level (T12 / L1). Educational objective: The portal vein can be identified on cross-sectional scans lying medial to (or just within) the right lobe of the liver and anterior to the inferior vena cava. The pressure in the portal system is elevated in liver cirrhosis.

A 53-Year-Old Man Who Has Not Seen a Physician in Years