Cirrhosis

Question 1

What will be found on investigation of a liver cirrhosis patient?

Answer 1

• low hemoglobin (N= 14 - 16)
• high MCV (N= 80 - 100)
• thrombocytopenia (N= 150 - 400)
• total bilirubin increased (N = 0 - 6)
• direct bilirubin increased (N = 0 - 0.3)
• AST/ALT ratio 2:1
• PT increased (N = 11 - 13.5)
• INR (N = 0.8 - 1.1)
• ammonia high (N = 11 - 32) -> encephalopathy

Question 2

What are the types of anemia?

Answer 2

MICROCYTIC
MCV < 80: iron deficiency OR thalassemia
- if microcytic anemia if found with liver disease -> look for bleeding

MACROCYTIC
MCV > 100
- megaloblastic: B12 OR folate deficiency
- non-megaloblastic: chronic liver cirrhosis, alcoholic, hypothyroidism

Question 3

What is the pathogenesis of liver cirrhosis?

Answer 3

• repetitive cell injury
• irreversible fibrosis
• loss of liver cell failure

Question 4

What is the most common age group where death due to liver cirrhosis occurs?

Answer 4

5th to 6th decades of life

Question 5

What are the causes of liver cirrhosis?

Answer 5

HEPATOTOXICITY

• long standing alcohol use
• medications (acetaminophen, methotrexate..)

HEPATITIS

• viral (hepatitis B, C, D)
• primary biliary cirrhosis
• primary sclerosing cholangitis
• autoimmune hepatitis
• parasitic infections

METABOLIC

• NASH
• hemochromatosis
• Wilson’s disease (due to seroplasmin deficiency)
• a1-antitrypsin deficiency

HEPATIC VEIN CONGESTION

• Budd-chiari syndrome
• Cardiac cirrhosis

Question 6

What are the dermal features of cirrhosis?

Answer 6

• pruritus
• jaundice
• telangiectasia -> spider angiomata
• caput medusa -> portal hypertension
• palmar erythema -> hyperestrogenemia
• petechiae & purpura -> thrombocytopenia
• white nails (leukonecya) -> hypoalbuminemia
• nail clubbing

Question 7

What are the GI & hormonal features of cirrhosis?

Answer 7

GI

• nausea, vomiting
• hepatosplenomegaly
• ascites

Hormonal (high estrogen)

• gynecomastia
• hypogonadism

Question 8

What are the other random symptoms of liver cirrhosis?

Answer 8

• asterixis
• fetor hepaticus
• dupuytren’s contracture
• peripheral edema (hypoalbuminemia)
• esophageal varices
• hemochromatosis -> dark bronze skin + diabetes
• Wilson’s disease -> neurological/psychiatric symptoms (parkinsonism & personality changes)
• alpha-1 antitrypsin deficiency -> lung emphysema

Question 9

What is the significance of a CBC in liver cirrhosis?

Answer 9

• microcytic anemia -> chronic blood loss
• macrocytic anemia -> B12 or folate deficiency
• thrombocytopenia -> due to hyperslpenism due to portal hypertension & decreased thrombopoietin production from the liver

Question 10

What is the effect of cirrhosis on the LFTs?

Answer 10

• AST > ALT -> if not more than 500 anything other than hepatitis (alcoholic) - if 1000s hepatitis
• bilirubin is initially normal or increased
• increased GGT, alkaline phosphatase, GDH, & ammonia
• decreased albumin
• increased PT & INR

Question 11

What labs should be done to determine the etiology of cirrhosis?

Answer 11

• HEPATITIS -> anti-HBs, anti-HBc, HBsAg, & anti-HCV
• a1 ANTITRYPSIN DEFICIENCY -> serum a1- antitrypsin
• HEMOCHROMATOSIS -> serum iron, ferritin
• WILSON -> serum & urine copper, serum ceruloplasmin
• AUTOIMMUNE -> hypergammaglobulinemia in serum protein electrophoresis, ASMA
• PBC -> + anti-mitochondrial antibodies (AMA or AMA-M2), increased alkaline phosphatase, increase bilirubin
• PSC -> GGT, alkaline phosphatase, bilirubin, pANCA increased + COLONOSCOPY

Question 12

How is liver cirrhosis treated?

Answer 12

• treat underlying condition
• avoid hepatotoxic substances (alcohol, paracetamol, NSAID)
• routine vaccinations
• balanced diet with no protein restriction
• propranolol or nadolol -> to decrease portal HTN
• spironolactone & furosemide -> to manage ascites & edema in patients with hypoalbuminemia
• treat complications

Question 13

What are the complications of liver cirrhosis & how are they treated?

Answer 13

• decompensated cirrhosis -> treat by relieving the stress & flushing out the extra fluid
• spontaneous bacterial peritonitis -> treated by IV ceftriaxone + albumin & oral FQ for life
• esophageal variceal hemorrhage -> treat by octreotide & band ligation & antibiotics until no more bleeding (ceftriaxone)
• hepatic encephalopathy -> treat using lactulose +- rifaximin or TIPS
• hepato renal syndrome -> treat by midodrine, octreotide, & albumin
• portal vein thrombosis -> treat by excision of thrombus +- anticoagulation (high risk of bleeding)
• portopulmonary hypertension -> treated by long term O2 or liver transplant
• HCC -> screen by US every 6 months

Question 14

How is spontaneous bacterial peritonitis diagnosed?

Answer 14

pericentesis of ascitic fluid will show granulocytes > 250

• commonly E. coli, helicobacter, Klebsiella

Question 15

What are the risk factors for hepatic encephalopathy?

Answer 15

• infection
• non adherence to meds
• constipation -> patient must defecate 2 - 3 times a day
• dehydration
• GI bleed
• portal vein thrombosis

Question 16

What is the cause of hepato-renal syndrome?

Answer 16

decreased renal blood flow leads to kidney injury -> increased creatinine by > 50%

Question 17

What is the cause of portopulmonary hypertension?

Answer 17

high cardiac output in advanced liver disease -> wall shear stress in pulmonary vasculature

• causes dyspnea & hypoxemia
• diagnosed by right heart catheterization