24. Liver cirrhosis Flashcards
what is the classification of hepatic cirrhosis according to MACROSOCPIC FEATURES
micro nodular cirrhosis = regenerating nodules less than 3mm
liver involved uniformly
= alcohol damage and billary tract disease
macro nodular
more than 3mm variable regenrating nodules in size
= chronic viral hepatitis
what is the clinical classification of cirrhosis ?
compensated
cirrhotic changes arre asymptomatic
compensated no ascitis no esophageal varicies no encephalopathy albumin > 35g/l bilirubin less than 20 mcmoll/L INR <1.5
decompensated ascitis esophageal varicose hepatic encephalopathy jaundice
what are the diagnostic modalities for cirrhosis ?
firm and hard but NON tender LIVER
SPLENOMEGALY
serum markers for fibrosis and cirrhosisi
US
loss of homogeneity and fibrous septae , rounded
margins
B mode and color doppler
portal vein diametre more than 13mm
splenic vein diametere more than 8 mm
loss of respiratory varietion in splenic an superior mesenteric vein
max velocity of blood flow through portal vein <20 cm/sec
volume of blood flow in portal vein <650ml/min
congestive index CI = cross sectional area / V mean > 0.1
US fibroscan = mechanical with shear wave propagation map
less than 11-12kPa = no cirrhosis
equal to or more than 14-12 kPa = cirrhosiss
esophageal endoscopy for varicose
CT
Liver biopsy - confirmation
HVPG - hepatic venous pressure gradient
wedged - free hepatic venous pressure
a balloon catheter is inserted using the transjugular route
under X-ray scopic control to measure the wedged hepatic venous pressure
blood = thrombocytopenia , / leukopenia and pancytopnea = spenomeglay
liver enzymes = asa and alt high
hyperbilirubinemia = direct
increase GGT
increase alkaline phosphatase
increase ammonia
increase prothrombin time
decrease in albumin
what is the current scoring system for cirrhosis ?
model of end stage liver disease
{3.8 x (LN bilirubin in mg/dl ) } + (9.6 x LN creation in md/dl) + (11.2 x LN (INR) ) + 6.6
mortality by MELD score less than 19 = 10 percent less than 30 = 24 percent less than 40 = 60 percent 40 and more = 81 percent
3 month observed mortality
what are the clinical presentation ?
perisiatnt jaundice acitis variciel bleeding jugular vein distention neurophyschiatric complication perisitnet hypotension and tachycardia
what is the management of compensated liver cirrhosis ?
treatment if according to etiology
alcohol abstinence
no aspirin use
low salt diet
adequate nutrition
antiviral therapy AIH = corticosteroid and azathioprine Primary billary cirrhosis = UDA wilson disease = chelators hemochromatosisi = phlebotomy
ULTRASOUND MONITORING FOR EARLY hoc every 6 months
measure Alpha fetoportien levels
1-3 years endoscopy for varicose
definition of portal hypertension?
portal venous pressure >5mmHg;
>10-12 mmHg develop clinical features or complications
what are the complication of liver cirrhosis ?
variciel bleeding
patent peraumbilical vein = caput medusa
portosystemic shunting due to portal hypertension - Abdominal “varices” – spleno-renal, spleno-gastric shunts= gastropathy and colonopathy
Rectal varices ~hemorrhoids
hepatic encephalopathy = occurs due t severe liver failure and and large protosystemic shunt
TRANSUDATE ascitis
high serum ascitis albumin gradient of more than 1.1g/dl
use amylase to exclude any pancreas induced ascitis
and pancreatitis there would be a low serum ascitis albumin gradient
hepatorenal syndrome
spontaneous bacterial peritonitis
malnutrition
cardiac dysfunction
hepatopulmonary syndrome
hyperesstrogeneism = spider angiomata
limited vit d activation = secondary hypeparthyroidims
Can we predict the presence of clinically significant portal hypertension (oesophageal varices with risk of bleeding) non-invasively
Baveno VI International Criteria
– Platelets > 150,000 / ul
and
– Liver stiffness measurement < 20 kPa
low clinical rik
what is the treatment for ascitis in decompensated liver ?
salt restriction
diuretics :
spironolactone
low does of loop diuretics = furosemide
if large volume ascitis = paracenthesisi
albumin infusion
increase the dose of diuretics mentioned above
TIPS = transjugular intraheptic portosttemic shunt
what is the treatment of sponatenus bacterial peritonitis for decompensated liver ?
ciprofloxacin IV (3rd gen cephalosporin )
amoxicillin and and clavunate iv
imepenem iv
what is the treatment for heptorenal syndrome for decompensated liver?
not enough blood flow to the kidney
vasoconstrictors = terlipressin in combination with intravenous albumin
liver transplant
what should be the treatment for patient with hepatic encephalopathy for decompensated liver ?
lactulose oral or enema or nasogastric tube
low absorbed antibiotic = rifaximin and neomycin
branched chain amino aids = l ornithine and l aspartate
liver transplant
what are the precipitating factor for hepatic encephalopathy ?
constipation protein intake GIT bleeding bacterial infection such as sepsis or pneumonia renal failure
what is the child pugh score ?
assessing the prognosis icnludingthe required strength for treatment and necessity of liver transplant
asses total bilirubin mg/dl
1 = less than 2
2
3 = more than 3
serum albumin g/dl
1 = more than 3.5
2
3 = less than 2.8
PT seconds above normal
1 = less than 4
2
3 = more than 6
ascitis
1 = none
2= mild
3 = moderate
hepatic encephalopathy
1 = none
2= minimal
3=advanced
class A = 5-6 points 1 year survival rate = 100
class b = 7-9 1 year survival rate =80 percent
class c =45 percent
