Causes and Complications of Cirrhosis

Question 1

General signs of advanced cirrhosis

Answer 1

-Weight loss except NAFLD not obvious (catabolic, cachectic)
-Jaundice (primary biliary cholangitis and primary sclerosing cholangitis)
-Unkempt (encephalopathy, alcoholic-related liver disease)

Question 2

Face signs of cirrhosis

Answer 2

-Jaundice (bilirubin above 50, Gilibert’s syndrome?)
-Xanthelasma (primary biliary cholangitis as hypercholesteremia)
-Paper dollar skin
-Rhinophyma (large nose)
-Seborrheic dermatitis (scaly rash related to rhinophyma- alcoholic)
-Parotid swelling- alcoholic liver disease (stones)

Question 3

Hands sign of cirrhosis

Answer 3

-Clubbing (relatively unusual)
-Polished nails (PBC- scratching)
-Leukonychia (low albumin)
-Dupuytren’s contracture (alcohol excess)
-Palmar erythema (alcoholic liver disease)
-Tremor (encephalopathic/ alcohol withdrawal)
-Bruising (clotting factors/ low platelets)
-Pigmentation (haemochromatosis)

Question 4

Legs sign of cirrhosis

Answer 4

-Ankle oedema (low albumin, lost oncotic pressure)
-Bruising
-Purpura
-Epistaxis

Question 5

Trunk signs of cirrhosis

Answer 5

-Reduced body hair (low testosterone)
-Gynaecomastia (oestrogen levels changed in metabolism/ spironolactone)
-Spider naevi >3 (drainage of superior vena cava- cirrhosis and pregnancy)!!!
-telangiectasia breast atrophy

Question 6

Abdomen signs of cirrhosis

Answer 6

-Hepatomegaly (early cirrhosis)
-Splenomegaly (portal hypertension, not as common)
-Portal hypertension or hepatic insufficiency
-Ascites (shifting dullness, umbilical herniation)
=Flatus
=Faeces
=Fat
=Fluid
=Foetus
-Dilated veins (portal hypertension)
-Testicular atrophy. irregular menses and amenorrhoea
-Umbilical hernia

Question 7

Treatment of bleeding oesophageal varices

Answer 7

Lower oesophageal sphincter- veins run in lumen to avoid muscular pressure= smaller veins prone to rupture

-Resuscitate from vomiting large amounts of blood
-Endoscopic therapy with band ligation (GA)
-Terlipressin- releases ADH to reduce portal pressure (2-3 days after bleeding)
-Balloon tamponade
-TIPSS (trans jugular intrahepatic portosystemic stent shunt): radiology technique, canula in right hepatic vein to portal vein to stent junction between portal vein and hepatic vein, resuce

Question 8

Prevention of rebleeding after oesophageal varices

Answer 8

-Secondary prophylaxis
-Band ligation (usually 5 times)
-Propranolol/nadolol/timolol/ carpindolol- reduces portal vein pressure

Question 9

Prevention of initial oesophageal varices bleed

Answer 9

-Primary prophylaxis
-Non-selective beta-blocker
-Variceal band ligation

Question 10

Treatment required for ascites in hepatic cirrhosis

Answer 10

-Sodium restriction (10-20%) (as renin Angio tension system)
-Plus, diuretics (70-80%)- spironolactone
-Other (resistant ascites) (10%)- transplant, TIPSS (can precipitate encephalopathy- uncleaned blood with ammonia to brain), paracentesis, intravenous albumin

Question 11

What is cirrhosis characterised by?

Answer 11

-Diffuse hepatic fibrosis
-Nodule formation
-Most common cause of portal hypertension

Question 12

Common causes of cirrhosis

Answer 12

-Chronic viral hepatitis (B or C)
-Prolonged excessive alcohol consumption
-NAFLD

Question 13

Immune causes of cirrhosis

Answer 13

-Primary sclerosing cholangitis
-Autoimmune liver disease

Question 14

Biliary causes of cirrhosis

Answer 14

-Primary biliary cholangitis
-Secondary biliary cirrhosis
-Cystic fibrosis

Question 15

Genetic causes of cirrhosis

Answer 15

-Haemochromatosis
-Wilson’s disease
-Alpha-1-antitrypsin deficiency

Question 16

Other causes of cirrhosis

Answer 16

-Cryptogenic (unknown-15%)
-Chronic venous outflow obstruction
-Cardiac hepatopathy with chronic hepatic congestion
-Any chronic liver disease

Question 17

Pathophysiology of cirrhosis

Answer 17

-Stellate cells in space of Disse activated by cytokines produced by Kupffer cells and hepatocytes
-Transforms into myofibroblast-like cell capable of producing collaging, pro-inflammatory cytokines and other mediators that promote hepatocyte damage and tissue fibrosis

Question 18

Histological diagnosis of cirrhosis

Answer 18

-Fibrosis markers (evolves over years) and widespread hepatocyte loss lead to distortion of liver architecture
=Disrupts hepatic vasculature, causing portosystemic shunts
=Patchy changes in biliary cirrhosis

Question 18

Symptoms of cirrhosis

Answer 18

-Weakness
-Fatigue
-Muscle cramps
-Weight loss
-Anorexia
-Nausea
-Upper abdominal discomfort

Question 19

Symptoms and signs of decompensated liver disease

Answer 19

-Jaundice
-Ascites
-Encephalopathy
-Variceal bleeding
-Hypalbuminaemia

Question 20

Nutrition in cirrhosis

Answer 20

-Malnutrition 50% decompensated cirrhosis
-35kcal/kg with 1.2-1,5g/kg protein

-Sarcopenia (loss of muscle mass)= higher rate of complications (infections, encephalopathy, ascites)
-Handgrip strength= assess muscle function

Question 21

Screening for complications

Answer 21

-Endoscopy= oesophageal varices
-Regular surveillance for hepatocellular carcinoma (AFP- alpha-fetoprotein)
-Bone density mineral density= osteoporosis and associated fractures
-Liver transplant

Question 22

Prognosis of cirrhosis

Answer 22

-Compensated= >12 years
-Decompensated= 2 years

-Child-Pugh
=Encephalopathy
=Primary biliary cholangitis
=Albumin
=PT time
=Ascites
-MELD

Question 23

4 main complications of cirrhosis

Answer 23

-Varices
-Ascites
-Encephalopathy
-Hepatocellular carcinoma

Question 24

What contributes to portal hypertension?

Answer 24

-increased blood flow to intestines
-Interruption to portal blood flow due to blockage

Question 25

Treatment for encephalopathy

Answer 25

-Rifaximin to get rid of colon bacteria that produces ammonia
-Low protein diet?
-Laxatives
-Transplant