cirrhosis

Question 1

what is cirrhosis?

Answer 1

histological definition: diffuse process in which the normal anatomical lobules of the liver are replaced by architecturally abnormal nodules separated by fibrous tissue.

Question 2

what is compensated and decompensated cirrhosis?

Answer 2

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.

Question 3

what is the basic pathophysiology of cirrhosis?

Answer 3

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

Question 4

what are the events that can cause decompensation to occur?

Answer 4

infection
surgery
portal vein thrombosis
GI bleeding
alcohol excess
drugs (eg NSAIDs, opiates)
development of HCC
dehydration
constipation

Question 5

what are the causes of cirrhosis most common in the UK?

Answer 5

alcohol misuse (alcohol liver disease)
NAFLD
hep B
hep C

Question 6

what are the signs of cirrhosis?

Answer 6

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

Question 7

what are the 5 stages of cirrhosis showing progression of the disease?

Answer 7

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

Question 8

what are 2 scores used to assess severity of cirrhosis and their components?

Answer 8

child’s pugh score -encephalopathy, ascites, billirubin, albumin, PT
UKELD score -billirubin, creatinine, sodium, INR

Question 9

how do you diagnose cirrhosis?

Answer 9

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

Question 10

who do you offer regular testing for cirrhosis for and how frequently?

Answer 10

every 2 years for:
alcoholic liver disease patients
hep C not responding to antivirals
NAFLD and advanced fibrosis

Question 11

what are the management strategies for cirrhosis?

Answer 11

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

Question 12

what happens in TIPS?

Answer 12

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

Question 13

what diuretic is used in ascites caused by cirrhosis?

Answer 13

spironolactone

Question 14

what is the most common complication of cirrhosis?

Answer 14

ascites

Question 15

what is hepatic encephalopathy and why does it happen?

Answer 15

dysfunction of brain as result of liver insufficiency/portosystemic shunting. related to effect of nitrogenous waste products (eg ammonia, glutamine) on the brain.

Question 16

what are the causes/predisposing events leading to HE?

Answer 16

constipation, dehydration, infection, GI bleed, drugs (opiates, benzos, diuretics)

Question 17

what is the management of hepatic encephalopathy?

Answer 17

treat underlying cause
oral lactulose -reduces ammonia growth in bowel
phosphate enemas
rifixamin for persistent HE or >1 admission with HE

Question 18

what is the management of variceal haemorrhage?

Answer 18

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

Question 19

why does hepatorenal syndrome happen?

Answer 19

changes to circulation due to effects of cirrhosis, sodium and water retention, and renal vasoconstriction, resulting in decrease in renal blood flow reducing eGFR

Question 20

what are the common types of primary liver cancer?

Answer 20

HCC -more than 90%
cholangiocarcinoma

Question 21

what is the most important risk factor for HCC?

Answer 21

cirrhosis

Question 22

what screening should cirrhosis patients have for HCC?

Answer 22

6 monthly USS

Question 23

what are the extra indications for liver transplant in HCC patients?

Answer 23

multiple tumours: up to 5 tumours all 3cm or less
single tumour: up to 5cm or up to 7cm if stable

Question 24

what are the complications of cirrhosis?

Answer 24

ascites
hepatic encephalopathy
variceal haemorrhage
infection
hepatorenal syndrome
HCC
portal hypertensive gastropathy
portal vein thrombosis
hypotension
cirrhotic cardiomyopathy

Question 25

why are people with cirrhosis more prone to infection and what are the most common infections?

Answer 25

cirrhosis causes immune dysfunction
spontaneous bacterial pneumonitis, UTI, pneumonia, cellulitis, bacteraemia

Question 26

what is portal hypertensive gastropathy?

Answer 26

changes to mucosa of stomach due to cirrhosis, usually due to increased blood flow, can cause gastric bleeding