Cirrhosis

Question 1

What is cirrhosis?

Answer 1

The pathological end-stage of any chronic liver disease, characterised by fibrosis and conversion of normal liver architecture to structurally abnormal nodules = regenerative nodules

Question 2

What are some causes of cirrhosis?

Answer 2

Viral Hepatitis B & C, alcohol-related liver disease, and non-alcoholic fatty liver disease, Autoimmune hepatitis, Drugs (e.g. methotrexate, hepatotoxic drugs)

Question 3

What is meant by “decompensated” cirrhosis?

Answer 3

1. Cirrhosis is considered DECOMPENSATED if it becomes complicated by any of:
   “J BAE”
   - Ascites
   - Jaundice
   - Encephalopathy
   - GI bleed (bleeding varices)
2. Decompensation can be precipitated by infection, GI bleeding, constipation, high-protein meal, electrolyte imbalances, alcohol and drugs, tumour development or portal vein thrombosis

Question 4

Summarise the epidemiology of cirrhosis

Answer 4

Among the top 10 leading causes of deaths worldwide

Question 5

What are the presenting symptoms/ signs of cirrhosis?

Answer 5

1. Abdominal Distension → symptom of decompensated cirrhosis secondary to ascites in portal hypertension
2. Jaundice and Pruritus (itch) → suggests decompensated cirrhosis secondary to reduced hepatic excretion of conjugated bilirubin
3. Encephalopathy → due to excess ammonia. May lead to confusion, altered GCS, asterixis.
4. Blood in Vomit (Haematemesis) and Black Stool (Melaena) → suggests decompensated cirrhosis secondary to GI haemorrhage (varices)
5. Hand and Nail features → Leukonychia (Hypoalbuminaemia), Palmar Erythema, Clubbing, Dupuytren Contracture (alcohol-related liver disease)
6. Spider Naevi (>4, fill from centre) and Gynaecomastia
7. Hepatomegaly & Splenomegaly
8. Portal Hypertension ⇒ ascites, splenomegaly, caput madusae. Causes swelling of veins (varices) in oesophagus and rectum.
9. A to J of Liver Failure ⇒ asterixis, bruising, clubbing, dupuytren’s contracture, erythema (palmar), fetor hepaticus, gynaecomastia, hepatomegaly, itching, jaundice 

Question 6

What investigations are used to diagnose/ monitor cirrhosis?

Answer 6

1. Liver Biopsy → most specific and sensitive test for diagnosis of cirrhosis.
2. Transient elastography
3. Upper GI Endoscopy → check for varices in patient’s with new diagnosis of cirrhosis
4. Liver Ultrasound (and AFP) every 6 months to check for hepatocellular cancer
5. Bloods
   - LFTs → deranged. AST & ALT levels increase with hepatocellular damage. Normally ALT>AST except for alcohol-related liver disease.
   - Serum Albumin → reduced. Marker of hepatic synthetic dysfunction.
   - PT → prolonged. Marker of hepatic synthetic dysfunction.
   - Serum Sodium → reduced. Common finding in cirrhotic patients with ascites. Hypervolaemic Hyponatraemia.
   (ABCDE = albumin, bilirubin, clotting, distention (ascites), encephalopathy)

Question 7

What score is used to estimate the prognosis in chronic liver disease/ cirrhosis?

Answer 7

Child-Pugh Grading - score for estimating the prognosis in chronic liver disease/cirrhosis.
Score 1:
- Bilirubin (umol/l) <34
- Albumin (g/l) >35
- Prothrombin time (seconds prolonged) <4
- Encephalopathy: none
- Ascites: none
Score 2:
- Bilirubin (umol/l) 34-51
- Albumin (g/l) 28-35
- Prothrombin time (seconds prolonged) 4-6
- Encephalopathy: mild
- Ascites: mild
Score 3:
- Bilirubin (umol/l) >51
- Albumin (g/l) <28
- Prothrombin time (seconds prolonged) >6
- Encephalopathy: marked
- Ascites: marked

Question 8

How is cirrhosis managed?

Answer 8

If due to alcoholic liver disease → abstinence from alcohol and good nutrition
1. Encephalopathy ⇒ lactulose (reduces absorption of ammonia in the gut). Rifaximin can be used as secondary prophylaxis.
2. Ascites → sodium restriction and diuretic therapy (spironolactone). Paracentesis (a hollow needle to remove fluid or gas) to drain.
3. Spontaneous bacterial peritonitis (SBP): elevated white cell count in the ascitic fluid (>250/mm3), and the predominance of neutrophils→ prophylactic antibiotics should be started immediately (ciprofloxacin or norfloxacin)
4. Surgical → TIPS (transjugular intrahepatic portosystemic shunt) to help reduce portal hypertension. Connects hepatic and portal vein.
- Reduces risk of oesophageal varices secondary to portal hypertension. May rupture which can lead to haematemesis. Terlipressin (vasopressin analogue) and IV antibiotics used in acute treatment, propanolol used as prophylaxis. Blood transfusion if Hb <7g/dL.
5. When the PT is prolonged (>14 seconds), intravenous vitamin K should be given immediately
6. Liver Transplantation → patients who develop complications of cirrhosis such as hepatocellular carcinoma