2+ Cirrhosis Flashcards
What is cirrhosis?
Diffuse pathological process characterised by fibrosis and conversion of normal liver architecture to regenerative nodules
Who is most likely to get cirrhosis?
M>F
Increases with age
What are the aetiologies of cirrhosis?
Hepatotoxicity:
- Chronic alcohol use
- Medications
Inflammation:
- Chronic viral hepatitis
- AI hepatitis
- PBC
- PSC
Metabolic Disorders:
- MAFLD
- Haemochrmatosis
- Wilson’s Disease
- Alpha 1 antitrypsin deficiency
- Hepatic vein congestion/Budd-chiari syndrome
What is the pathophysiology of cirrhosis?
The final stage of ANY chronic liver disease
- Activation of hepatic stellate cells –> accumulation of collagen types I and II –> perturbs blood flow –> portal HTN
- Ongoing scarring and fibrosis with nodular regeneration –> also causes portal HTN by increasing resistance in the sinusoids and terminal portal venules
How is cirrhosis classified?
Compensated:
- Biochemical, histological findings are present
- Liver function is preserved
- No evidence of complications related to portal HTN
Decompensated:
- Evidence of complications: reduced synthetic function and portal HTN –> ascites, varices, hepatic encephalopathy, jaundice
What is the history on clinical presentation of cirrhosis?
- Fatigue, malaise, weight loss
- Jaundice, pruritus
- Skin changes: dry and atrophic
- Amenorrhea
- RFs: alcohol use, IVDU, unprotected sex, obesity
What do you find on examination of a patient with cirrhosis?
Peripheral:
- Dupuytren’s, asterixis, pruritus, palmar erythema, leukonychia
- Fetor hepaticus
- Spider naevi, gynaecomastia, loss of hair
- Peripheral oedema
Abdominal
- Caput medusae
- Hepatosplenomegaly
- Ascites/distension
What laboratory tests do you do when you suspect cirrhosis?
LFTs:
- Can be normal!!
- AST and ALT elevated = hepatocellular damage
- ALT greater in most (besides alcohol)
- BR may be normal in compensated cirrhosis
- GGT elevated
Coags:
- Prolonged PTT = decompensated
UEC:
- low sodium
FBC:
- Low albumin
- Low platelets (from portal HTN with hypersplenism)
What immunology labs do you do in someone presenting with suspected cirrhosis?
- Viral hepatitis serology
- ANCA, ANA, ASMA for AI hepatitis
What imaging/confirmatory tests do you do when you suspect cirrhosis?
USS:
- Nodular and shrunken liver
- Hepatic/portal vein abnormalities
- Transient Elastostography for detecting fibrosis and cirrhosis without need for biopsy
Liver biopsy:
- Most specific and sensitive but most patients don’t need it as you don’t need to determine the exact degree of inflammation
- Do it if you are unsure of the underlying cause
How do you stage cirrhosis?
Child-Pugh-Turcotte (CPT)
- Based on the presence of ascites and hepatic encephalopathy,
serum BR, albumin and clotting (PTT and INR)
What is the management of cirrhosis?
- Treat the underlying cause
- Avoid hepatotoxic substances
- Routine vaccinations
- Monitor for complications
Medical:
- Ascites: sodium restriction + spironolactone/frusemide
- Bleeding: Vit K
- Non-specific BB (portal HTN): propranolol
Interventional:
- Ascitic tap/paracentesis
- Liver transplanation
- Transjugular intrahepatic portosystemic shunt (TIPS): connects the portal veins to blood vessels that are lower pressure
What are the complications of cirrhosis?
- Decompensated cirrhosis –> jaundice, ascites, variceal
haemorrhage, encephalopathy - Bleeding and thrombosis
- Hepatocellular carcinoma
- Spontaneous bacterial peritonitis
- Hepatic hydrothorax
- Acute kidney injury from hepatorenal syndrome (renal
vasoconstriction/hypoperfusion) - Hepatopulmonary syndrome
- Hypogonadism in men
- Portal HTN –> formation of portosystemic venous collaterals
