Cirrhosis Flashcards
What is cirrhosis?
Result of chronic inflammation + damage to liver cells which are replaced with scar tissue (fibrosis) forming nodules
How does portal hypertension result?
Fibrosis causes increased resistance in vessels leading to the liver
4 most common causes of cirrhosis?
(1) Alcoholic liver disease (AST x2 ALT)
(2) Non-alcoholic fatty liver disease
(3) Hep B
(4) Hep C
Whats drugs can cause cirrhosis?
Amiodarone, methotrexate, sodium valproate
Genetic disorders that can cause cirrhosis?
- Wilson’s disease (copper deposition)
- Haemochromatosis (iron overload)
- Alpha-1 antitrypsin deficiency
- Cystic fibrosis
Signs of Wilson’s disease?
Copper deposition:
- Kayser-fleischer rings (eyes)
- Osteopenia
- Parkinsonism
2x autoimmune conditions causing cirrhosis?
(1) Autoimmune hepatitis
(2) Primary biliary cirrhosis
Signs of cirrhosis?
- Jaundice
- Hepatomegaly
- Splenomegaly
- Asterixis
- Gynaecomastia
- Palmar erythema
- Spider naevi
- Easy bruising
- Ascites
- Caput Medusae –> distended paraumbilical veins due to portal hypertension
What blood result indicates fluid retention in severe liver disease?
Hyponatraemia
What blood test can be checked every 6 months alongside and US and why?
Alpha-fetoprotein - tumour marker for HCC
1st line investigation for non-alcoholic fatty liver disease?
Enhanced liver fibrosis (ELF) blood test
What does an EFL score of <7.7 indicate?
none to mild fibrosis
What does an EFL score of 7.7-9.8 indicate?
moderate fibrosis
What does an EFL score of >9.8 indicate?
severe fibrosis
Signs of cirrhosis on USS?
(1) Nodular surface
(2) ‘Corkscrew’ appearance to arteries
(3) Enlarged portal vein
(4) Ascites or splenomegaly
Which patients would you perform a Fibroscan every 2 years?
Those risk of cirrhosis:
- Hep C/B
- alcoholic liver disease
- heavy alcohol drinkers
- non-alcoholic fatty liver + fibrosis evidence on ELF test
Every year for chronic Hep B
Investigation to confirm diagnosis of cirrhosis?
Liver biopsy
What score is used for cirrhosis to determine severity?
Child-Pugh Score
What score gives an estimated 3 month mortality and helps guide liver transplant referral?
MELD score (every 6 months if compensated cirrhosis)
General management
(1) USS + alpha-fetoprotein every 6 months (HCC?)
(2) MELD score every 6 months (liver transplant?)
(3) Endoscopy every 3yrs if varices
(4) High protein, low sodium diet
Where does the portal vein come from?
Superior mesenteric vein + splenic vein
How do varices develop?
Cirrhosis causes portal hypertension –> back pressure causes sites where the portal system anastamoses w/ the systemic venous system become swollen + tortuous (varices)
4 sites of varices?
(1) gastro-oesophageal junction
(2) ileocaecal junction
(3) rectum
(4) caput medusae - ant. abdo wall via umbilical vein
Treatment for stable varices?
Medical + endoscopy!
- propanolol
- elastic band ligation
- TIPS
Resus for bleeding oesophageal varices?
- terlipressin
- vit K + FFP
- broad spectrum abx
What can be done with endoscopy for bleeding varices?
(1) elastic band ligation
(2) inject sclerosant
What can be used if endoscopy fails to stop bleeding in oesophageal varices?
Sengstaken-Blakemore Tube
How does ascites form?
High pressure in portal system causes fluid to move from vessels into peritoneal cavity. Drop in BP causes renin release –> aldosterone release –> reabsorption of Na + fluid
Management of ascites?
(1) low sodium diet
(2) Spironolactone (anti-aldosterone)
(3) Paracentesis (tap or drain)
(4) Prophylactic antibiotics (ciprofloxacin/norfloxacin) if <15g/L protein in fluid
Management of refractory ascites?
- TIPS
- Transplantation
Is ascitic fluid low or high in protein if caused by cirrhosis?
low ?
When to suspect spontaneous bacterial peritonitis (SBP)?
10% of patients with ascites secondary to cirrhosis:
- fever
- abdo pain
- ileus
- hypotension
- derranged bloods (raised WCC, CRP, creatinine OR metabolic acidosis)
Most common causes of SBP?
(1) E. Coli
(2) Klebsiella pneumoniae
(3) G +ve cocci (staphylococcus, enterococcus)
Management of SBP?
- ascitic culture (before abx)
- IV cephalosporin (cefotaxine)
Hepatorenal syndrome is fatal unless what?
Fatal within a week or so unless liver transplant
How might hepatic encephalopathy present?
Cirrhosis patient!
Acute - reduced LOC, confusion
Chronic - changes in personality, mood, memory
Precipitating factors of hepatic encephalopathy?
(1) constipation
(2) electrolyte disturbance
(3) infection
(4) GI bleed
(5) high protein diet
(6) sedatives
Management of hepatic encephalopathy?
- LACTULOSE (laxatives) get rid of ammonia before absorbed
- ABX (RIFAXIMIN)
Diagnosis of cirrhosis?
Tranditionally liver biospy
FIbroscan now used (transient elastography)
AST, ALT blood result to mark degree of necoinflammatory activity in patients with cirrhosis?
AST 2.5x raised as ALT
AST 10x raised as ALT if chronic hepatitis
Best blood test to investigate cirrhosis in patient with chronic liver disease?
Platelets! (<150,000mm3)
Domains of child-pugh score (useful things to indicate severity of cirrhosis)?
(1) Bilirubin - increases
(2) Albumin - decreases
(3) PT - prolonges
(4) Encephalopathy
(5) Ascites
Domains of MELD score?
(1) bilirubin
(2) creatinine
(3) INR
