cirrhosis

Question 1

What are risk factors for cirrhosis?

Answer 1

• alcohol misuse
• intravenous drug use
• unprotected intercourse
• obesity
• birth country

Question 2

What are key diagnostic features of cirrhosis?

Answer 2

• presence of risk factors
• abdominal distension
• jaundice and pruritus
• blood in vomit (haematemesis) and black stool (melaena)

Question 3

What abdominal features are seen in cirrhosis?

Answer 3

• caput medusa
• bruising
• hepatomegaly
• splenomegaly
• abdominal distension with shifting dullness and fluid thrill secondary to ascites
• hepatic bruit (may be present with a vascular hepatoma)
• loss of secondary sexual hair and testicular atrophy in men

Question 4

What are facial features seen in cirrhosis?

Answer 4

• telangiectasia (red focal lesions resulting from irreversible dilatation of small blood vessels in the skin)
• spider naevi (blanch on pressure and spider-like branches fill from a central arteriole)
• bruising
• rhinophyma
• parotid gland swelling
• paper-money appearance of the skin (randomly distributed thready blood vessels)
• red tongue in alcohol-related liver disease
• seborrhoeic dermatitis
• jaundiced sclera
• xanthelasma (yellow plaques on eyelids secondary to lipid deposition) in primary biliary cholangitis.

Question 5

What are some hand & nail features of cirrhosis?

Answer 5

• leukonychia (white nails) secondary to hypoalbuminaemia
• polished nails secondary to excessive scratching in pruritus
• palmar erythema (redness of thenar and hypothenar eminences)
• spider naevi (blanch on pressure and spider-like branches fill from a central arteriole)
• bruising
• finger clubbing
• cholesterol deposits in palmar creases in primary biliary cholangitis
• Dupuytren contracture in alcohol-related liver disease.

Question 6

What blood Ix would you give for cirrhosis in order, and what would they look like?

Answer 6

• liver function tests (AST & ALT high)
• gamma-glutamyl transferase (GGT) - elevated
• serum albumin - reduced
• serum sodium - reduced (ascites)
• PT time - prolonged
• Plt count - reduced
• antibodies to hep c virus - present
• Hep b antigen - present

Question 7

What can we use to score the severity of cirrhosis?

Answer 7

Child pugh turcotte aka CPT

or model of end stage liver disease aka MELD

Question 8

1st line Tx for cirrhosis?

Answer 8

Oral direct-acting antivirals chronic hepatitis C virus infection.

Avoidance of alcohol + other hepatotoxic drugs eg NSAIDs, paracetamol - Superimposed hepatic insult

immunisation against hepA/B for susceptible patients

Management of metabolic risk factors, maintenance of adequate nutrition, and regular exercise

Question 9

What complications arise from cirrhosis?

Answer 9

portal hypertension causing ascites

gastro-oesophageal varices

portosystemic encephalopathy

AKI

hepatopulmonary syndromes

portopulmonary hypertension

hepatocellular carcinoma

Question 10

How can we monitor for the complications in cirrhosis?

Answer 10

abdominal US - detection of ascites

upper GI endoscopy - detection of gastro-oesophageal varices

abdominal US, CT, MRI - detection of hepatocellular carcinoma.

Question 11

What is 2nd line Tx for decompensated cirrhosis?

Answer 11

Liver transplant

transjugular intrahepatic portosystemic shunt (TIPSS)

Question 12

What are facial features seen in cirrhosis?

Answer 12

• telangiectasia (red focal lesions resulting from irreversible dilatation of small blood vessels in the skin)
• spider naevi (blanch on pressure and spider-like branches fill from a central arteriole)
• bruising
• rhinophyma
• parotid gland swelling
• paper-money appearance of the skin (randomly distributed thready blood vessels)
• red tongue in alcohol-related liver disease
• seborrhoeic dermatitis
• jaundiced sclera
• xanthelasma (yellow plaques on eyelids secondary to lipid deposition) in primary biliary cholangitis.

Question 13

What is the prognosis of cirrhosis?

Answer 13

• compensate cirrhosis - 10 years
• decompensated - 2 years
• depends on the stage:
• Stage 1
• Patients without gastro-oesophageal varices or ascites have a mortality of approximately 1% per year.
• Stage 2
• Patients with gastro-oesophageal varices (but no bleeding) and no ascites have a mortality of approximately 4% per year.
• Stage 3
• Patients with ascites with or without gastro-oesophageal varices (but no bleeding) have a mortality of approximately 20% per year.
• Stage 4
• Patients with gastrointestinal bleeding due to portal hypertension with or without ascites have a 1-year mortality of 57%.