Cirrhosis

Question 1

what is cirrhosis

Answer 1

end stage of liver damage due to chronic, heavy alcohol intake

Question 2

histology of cirrhosis

Answer 2

normal liver architecture is replaced with diffuse fibrosis and nodules of regenerating hepatocytes

Question 3

what is decompensated cirrhosis

Answer 3

acute deterioration of someone with cirrhosis

Question 4

what complications lead to decompensation

Answer 4

ascites, jaundice, encephalopathy and GI bleeding

Question 5

what can decompensation be precipitated with

Answer 5

infection, GI bleeding, constipation, high-protein meal, electrolyte imbalance, alcohol, drugs, tumour development or portal vein thrombosis

Question 6

aetiology of cirrhosis

Answer 6

mainly chronic alcohol misuse, chronic viral hepatitis (unproductive sex, sharing needles - body fluid exchange)
autoimmune hepatitis, drugs, inherited, vascular, chronic biliary diseases, not known or non-alcohol related steatohepatitis

Question 7

what are inherited causes of cirrhosis

Answer 7

haemochromatosis, Wilsons disease, galactosaemia, cystic fibrosis, alpha 1- antitrypsin deficiency

Question 8

non-alcohol related steatohepatitis (NASH)

Answer 8

obesity and diabetes

Question 9

presenting symptoms (early, non-specific)

Answer 9

anorexia, nausea, fatigue, weakness and weight loss

Question 10

why weight loss in cirrhosis

Answer 10

liver can’t process nutrients, and vomitting?

Question 11

presenting symptoms (liver synthetic functions decreased)

Answer 11

easy bruising, abnormal swelling, ankle oedema

Question 12

presenting symptoms (liver detoxification functions decreased)

Answer 12

jaundice, personality change, altered sleep pattern, amenorrhoea, galactorrhea

Question 13

presenting symptoms (portal hypertension)

Answer 13

abdominal swelling, haematemesis (vomiting blood) and PR bleeding

Question 14

epidemiology

Answer 14

one of top 10 causes of death worldwide

Question 15

physical examination findings

Answer 15

abdominal distension, jaundice, haematemesis (blood in vomit), black stool (melaena), hand and nail features (clubbing, spider naevi, palmar erythema), hepatomegaly, splenomegaly, muscle wasting and peripheral oedema

Question 16

investigations

Answer 16

bloods; FBC, LFT’s, clotting and serum AFP (alpha fetoprotein)

Question 17

what would you see in FBC

Answer 17

low platelet (thrombocytopenia) and low Hb due to portal hypertension- leads to hypersplenism

Question 18

what would you see in LFT’s

Answer 18

high ALP, ALT, GGT, AST and bilirubin. low albumin

Question 19

what would you expect to see regarding Prothrombin Time (PT)

Answer 19

prolonged in cirrhosis

Question 20

why is alpha fetoprotein important

Answer 20

its a marker for liver cancer so high levels may suggest hepatocellular carcinoma

Question 21

management (TREAT THE CAUSE)

Answer 21

Avoid alcohol, sedatives, opiates, NSAIDs and drugs that affect the liver
Nutrition is important
Enteral supplements should be given
NG feeding may be indicated

Question 22

treating encephalopathy

Answer 22

Treat infections
Exclude GI bleed
Use lactulose and phosphate enemas
Normally, the liver breaks down ammonia that is absorbed in the GI tract, however, in Cirrhosis the ammonia can go through the liver without being broken down and exert toxic effects on the brain
IMPORTANT: lactulose reduces the absorption of ammonia from the gut
This helps prevent encephalopathy caused by ammonia reaching the brain
Avoid sedation

Question 23

treating ascites

Answer 23

Diuretics (spironolactone with/without furosemide)
Dietary sodium restriction
Therapeutic paracentesis (with human albumin replacement)
Monitor weight
Fluid restrict if plasma sodium < 120 mmol/L
Avoid alcohol and NSAIDs

Question 24

treating spontaneous bacterial peritonitis

Answer 24

Antibiotics (e.g. cefuroxime and metronidazole)

Prophylaxis against recurrent SBP with ciprofloxacin

Question 25

surgical treatment

Answer 25

TIPS (trans jugular intrahepatic portosystemic shunt)

liver transplant is only CURE

Question 26

possible complications

Answer 26

Portal hypertension with ascites  
Hepatic encephalopathy 
Variceal haemorrhage  
SBP 
HCC 
Renal failure (hepatorenal syndrome)  
Pulmonary hypertension (hepatopulmonary syndrome)

Question 27

prognosis?

Answer 27

Generally poor prognosis
Overall 5 year survival = 50%
If ascites, 2 year survival = 50%