cirrhosis Flashcards
what is cirrhosis?
histological definition: diffuse process in which the normal anatomical lobules of the liver are replaced by architecturally abnormal nodules separated by fibrous tissue.
what is compensated and decompensated cirrhosis?
compensated: when the liver can still function effectively and there are no or few noticeable clinical symptoms
decompensated: when the liver is damaged to the point that it cannot function adequately and overt clinical complications such as jaundice, ascites, variceal haemorrhage, and hepatic encephelopathy are present.
what is the basic pathophysiology of cirrhosis?
increased resistance from backlog in liver
portal hypertension
splanchnic vasodilation
systemic vasodilation leads to hypotension and activation of RAAS system
increased Na+ and water retention
what are the events that can cause decompensation to occur?
infection
surgery
portal vein thrombosis
GI bleeding
alcohol excess
drugs (eg NSAIDs, opiates)
development of HCC
dehydration
constipation
what are the causes of cirrhosis most common in the UK?
alcohol misuse (alcohol liver disease)
NAFLD
hep B
hep C
what are the signs of cirrhosis?
general: muscle wasting, jaundice, abnormal bruising
hands: palmar erythema, white nails, asterexis
face: sclera jaundice
abdo: spider naevi, hepatomegaly, splenomegaly, palpable left lobe of liver, ascites
peripheral oedema, gait from encephelopathy
what are the 5 stages of cirrhosis showing progression of the disease?
stage 1: compensated without varices
stage 2: compensated with varices
stage 3: variceal bleeding without any other complications
stage 4: first non bleeding complication eg ascites, HE, jaundice
stage 5: any second decompensating event
what are 2 scores used to assess severity of cirrhosis and their components?
child’s pugh score -encephalopathy, ascites, billirubin, albumin, PT
UKELD score -billirubin, creatinine, sodium, INR
how do you diagnose cirrhosis?
transient elastography (fibroscan) in NAFLD, hep C, alcohol liver disease/heavy drinkers for several months
refer to specialist to diagnose if TE not available/suitable, hep B, other liver disorders
who do you offer regular testing for cirrhosis for and how frequently?
every 2 years for:
alcoholic liver disease patients
hep C not responding to antivirals
NAFLD and advanced fibrosis
what are the management strategies for cirrhosis?
info giving
dietary advice
alcohol reduction
smoking cessation
treat underlying liver disease
referral if indicated
liver transplant if indicated
TIPS
diuretics
screen and manage complications
what happens in TIPS?
transjugular intrahepatic port-systemic shunt
shunt from hepatic vein to intrahepatic portal vein sustained by metal stent
needs to be large enough to effectively decrease portal pressure but small enough not to cause liver failure and hepatic encephalopathy
what diuretic is used in ascites caused by cirrhosis?
spironolactone
what is the most common complication of cirrhosis?
ascites
what is hepatic encephalopathy and why does it happen?
dysfunction of brain as result of liver insufficiency/portosystemic shunting. related to effect of nitrogenous waste products (eg ammonia, glutamine) on the brain.
what are the causes/predisposing events leading to HE?
constipation, dehydration, infection, GI bleed, drugs (opiates, benzos, diuretics)
what is the management of hepatic encephalopathy?
treat underlying cause
oral lactulose -reduces ammonia growth in bowel
phosphate enemas
rifixamin for persistent HE or >1 admission with HE
what is the management of variceal haemorrhage?
A-E -fluids, bloods, high flow 02, consider intubation
terlipressin straight away if ?variceal bleeding
antibiotics as soon as ?variceal bleeding
oesophageal varices: 1st line band ligation, 2nd line consider TIPS
gastric varices: 1st line endoscopic injection of N-butyl-2-cyanoacrylate (n-BCA, NBCA), 2nd line TIPS
why does hepatorenal syndrome happen?
changes to circulation due to effects of cirrhosis, sodium and water retention, and renal vasoconstriction, resulting in decrease in renal blood flow reducing eGFR
what are the common types of primary liver cancer?
HCC -more than 90%
cholangiocarcinoma
what is the most important risk factor for HCC?
cirrhosis
what screening should cirrhosis patients have for HCC?
6 monthly USS
what are the extra indications for liver transplant in HCC patients?
multiple tumours: up to 5 tumours all 3cm or less
single tumour: up to 5cm or up to 7cm if stable
what are the complications of cirrhosis?
ascites
hepatic encephalopathy
variceal haemorrhage
infection
hepatorenal syndrome
HCC
portal hypertensive gastropathy
portal vein thrombosis
hypotension
cirrhotic cardiomyopathy
