Cirrhosis

Question 1

What is cirrhosis?

Answer 1

Diffuse pathological process, characterised by fibrosis and conversion of normal liver architecture→ structurally abnormal nodules (called regenerative nodules).

Can arise from many causes and is final stage of any chronic liver disease.

Question 2

What can cirrhosis cause?

Answer 2

PHTN, liver failure, hepatocellular carcinoma, etc.

Question 3

Pathophysiology of cirrhosis?

Answer 3

Fibrosis occurs in most chronic liver injury→ may evolve into cirrhosis w nodule formation.

Central mechanism in hepatic fibrosis: activation of hepatic stellate cells (major source of extracellular matrix)→ accumulation of collagen in hepatic parenchyma

Overall progression→ disrupted liver blood flow→ increased portal venous pressure+ directing blood away from liver→ ascites, gastro-oesophageal varices, hepatic encephalopathy, etc

Question 4

How can acute insults lead to acute decompensation in cirrhosis?

Answer 4

Acute insults (ie: infection)→ changes in vascular tone→ influence portal pressure→ acute decompensation

Question 5

What is decompensated cirrhosis?

Answer 5

Acute deterioration in liver function in a patient w cirrhosis. Characterised by jaundice, ascites,hepatic encephalopathy, hepatorenal syndrome or variceal haemorrhage

Question 6

Aetiology of cirrhosis? (lots!)

Answer 6

Any chronic liver disease
Alcoholic liver disease, non-alcoholic fatty liver disease, Hep C and B

Metabolic disorders (inclu: Wilson’s, haemochromatosis, etc)

Cholestatic and autoimmune: primary biliary cholangitis, primary sclerosing cholangitis, autoimmune hepatitis

Biliary obstruction

Hepatic venous outflow obst (R sided heart failure)

Drugs (amiodarone, methotrexate)

Question 7

Risk factors for cirrhosis?

Answer 7

Alcohol misuse
IVDU
Unprotected intercourse
Obesity
Certain global regions where Hep B, C endemic
Blood transfusions (weak)
Tattooing (weak)

Question 8

Abdominal/ GIT signs and symptoms of cirrhosis?

Answer 8

• Abdominal distention (esp flanks)
• Jaundice and pruritus
• Haematemesis and melaena
• Caput medusa
• Bruising
• Hepatomegaly and splenomegaly
• Ascites (shifting dullness and fluid thrill) and hepatic bruit

Question 9

Hands and nails features of cirrhosis? (3)

Answer 9

Leukonychia, palmar erythema, spider naevi

Question 10

Facial features of cirrhosis?

Answer 10

Telangiectasia: red focal lesions resulting from irreversible dilatation of small blood vessels in skin

Bruising
Jaundiced sclera
Xanthelasma

Question 11

Other signs and symptoms of cirrhosis? (exclu. abdominal, facial, hands and nails)

Answer 11

• Constitutional symptoms: fatigue, weakness, weight loss
• Peripheral oedema
• Altered mental state (uncommon)

Question 12

Ix: Investigations for cirrhosis?

Answer 12

Bloods
IF deranged LFTS: USS first line, CT
IF confusion with decompensated liver disease→ check blood glucose!
Endoscopy
Liver biopsy
Ascitic tap
Investigate CAUSE

Question 13

Ix: Bloods results for cirrhosis may show?

Answer 13

• LFTs: deranged (high AST, ALT, GGT)
• Serum albumin and sodium: low
• Prothrombin time: elevated
• Platelet count: low
• Serum AFP (alpha-fetoprotein)→ hepatocellular carcinoma; protein indicative of rapid cell division

Question 14

Ix: USS/ CT for cirrhosis may show?

Answer 14

• Ascites
• Hepatomegaly
• HCC
• Portal HTN

Question 15

Ix: Liver biopsy for cirrhosis may show?

Answer 15

Periportal fibrosis
Nodules

Question 16

Ix: Investigations for potential causes of cirrhosis?

Answer 16

• Iron studies: haemochromatosis
• ASMA/ANA: autoimmune
• Viral serology (Hepatitis, EBV, HIV, etc)
• Caeruloplasmin: low levels could indicate Wilson’s disease (rare inherited disorder,copper accum in liver, brain, etc)
• A1-antitrypsin

Question 17

First line management of cirrhosis?

Answer 17

• Treat underlying chronic liver disease + monitor for complications + supportive care
• Consider: sodium restriction and diuretics for ascites

Question 18

Second line management for cirrhosis?

Answer 18

• Liver transplant (if complications/ decompensation)
• IF not suitable for transplant: transjugular intrahepatic portosystemic shunt (TIPSS)