Cirrhosis

Question 1

What is liver cirrhosis?

Answer 1

Cirrhosis = result of chronic inflammation within the liver cells that leads to damage
Hepatocytes are replaced with scar tissue –> forming nodules of scar tissue within the liver

Question 2

What are the four most common causes of cirrhosis?

Answer 2

Alcoholic liver disease
Hepatitis B
Hepatitis C
NAFLD

Question 3

What are other causes of cirrhosis?

Answer 3

Genetic: Wilson’s, alpha1ATD, HH, CF
AI: AH, PBC, PSC
Neoplasm: HCC, metastasis
Vascular: Budd-Chiari, RHF, constrictive pericarditis

Question 4

What are the signs of cirrhosis in the hands?

Answer 4

Jaundice --> increased bilirubin
Clubbing --> PBC 
Leuconychia --> low albumin
Palmar erythema
Dupytren's contracture

Question 5

What are the signs of cirrhosis in the face?

Answer 5

Jaundice - elevated bilirubin
Pallor - anaemia
Xanthelasma - PBC

Question 6

What are the signs of cirrhosis in the trunk and abdomen?

Answer 6

Spider naevi (>5) - telengectasia with central arteriole 
Gynaecomastia - feminisation 
Loss of secondary sexual characteristic hair -feminisation 

Bruising due to abnormal clotting
Caput medusa - distended superficial paraumbilical veins due to portal hypertension
Hepatomegaly - can shrink as it becomes more cirrhotic
Splenomegaly - due to portal hypertension
Ascites
Testicular atrophy - feminisation

Question 7

What would blood tests show in cirrhosis?

Answer 7

Bloods:
FBC - maybe ↑MCV ↓WCC and ↓platelets = hypersplenism
↑LFTs 
↑INR / PT
↓albumin

Question 8

How do you find the cause of the cirrhosis

Answer 8

Alcohol - ↑MCV, ↑GGT
NASH - hyperlipidaemia and ↑glucose
Infection - HepB/C serology, CMV and EBV serology
Genetic - Ferritin, alpha1AT, caeruloplasmin (↓ in Wilson’s)
Autoimmune: Antibodies - lots of crossover
Cancer - alpha-foetoprotein

Question 9

What are the antibodies you look for in cirrhosis?

Answer 9

Autoimmune hepatitis: SMA, SLA, LKM, ANA
PBC: AMA
PSC: ANCA, ANA

Question 10

What Ig can you test for in cirrhosis?

Answer 10

Ig: ↑IgG in AIH and ↑IgM in PBC

Question 11

What imaging do you do in cirrhosis?

Answer 11

Abdo US showing:
Small or large liver
Focal lesions/ nodularity of liver surface
Corkscrew appearance of arteries compensating for reduced portal flow
Ascites
Reversed portal vein flow

US used to screen for HCC

Question 12

What other investigations would you do?

Answer 12

Ascitic tap & MCS
–> Polymorphic neutrophil count >250mm^3 indicates SBP

Liver biopsy - to confirm diagnosis of cirrhosis