Cirrhosis

Question 1

What is cirrhosis?

Answer 1

End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis + nodules of regenerating hepatocytes.

Question 2

When is cirrhosis considered decompensated?

Answer 2

Once it becomes complicated by: 
Ascites  
Jaundice 
Encephalopathy 
GI bleed

Question 3

List 8 causes of cirrhosis

Answer 3

Chronic alcohol misuse (most common in UK)
Chronic viral hepatitis (hep B/C: most common worldwide)
AI hepatitis
Drugs (e.g. methotrexate, hepatotoxic drugs)
Inherited
Vascular: Budd-Chiari Syndrome, Hepatic Venous Congestion
Chronic Biliary Diseases: PBC, PSC, Biliary atresia
Unknown: 5-10%
Non-Alcoholic Steatohepatitis (NASH)

Question 4

What things may precipitate decompensation?

Answer 4

Infection
GI bleeding
Constipation
High-protein meal
Electrolyte imbalances
Alcohol + drugs
Tumour development
Portal vein thrombosis

Question 5

Describe the epidemiology of cirrhosis

Answer 5

In top 10 causes of death worldwide

Question 6

List 5 early non-specific symptoms in cirrhosis

Answer 6

Anorexia 
Weight loss
Nausea  
Fatigue  
Weakness

Question 7

List 3 symptoms caused by reduced liver synthetic function

Answer 7

Easy bruising
Abnormal swelling
Ankle oedema

Question 8

List 5 symptoms caused by reduced detoxification function

Answer 8

Jaundice  
Personality change  
Altered sleep pattern  
Amenorrhoea 
Galactorrhoea

Question 9

List 3 symptoms caused by portal HTN

Answer 9

Abdominal swelling
Haematemesis
PR bleeding or melaena

Question 10

What are the ABCDE signs in cirrhosis?

Answer 10

Asterixis 
Bruises  
Clubbing  
Dupuytren's contracture 
Palmar erythema

Question 11

List 11 signs of cirrhosis

Answer 11

Jaundice  
Gynaecomastia  
Leukonychia  
Parotid enlargement  
Spider naevi 
Scratch mark (from cholestatic pruritis)  
Ascites (shifting dullness)
Enlarged liver (shrunken in later stages)  
Testicular atrophy 
Caput medusae  
Splenomegaly

Question 12

What bloods should be investigated in cirrhosis?

Answer 12

FBC: low platelets + Hb = because of hypersplenism due to portal HTN
LFTs: some normal, but often get:
High AST, ALT, ALP, GGT + BR
Low albumin
Clotting: prolonged PT (decreased synth of clotting factors)
Serum AFP (tumour marker for liver cancer):
Raised in chronic liver disease but high levels may suggest hepatocellular carcinoma

Question 13

Why should an Ascitic Tap be performed in cirrhosis?

Answer 13

MC+S : check for infection
Biochemistry (protein, albumin, glucose, amylase)
Cytology
If neutrophils > 250/mm3 = spontaneous bacterial peritonitis (SBP)

Question 14

Which method of liver biopsy is used in cirrhosis? What are the histopathological features?

Answer 14

Percutaneously 
Transjugular (if clotting deranged or ascitic) 

Periportal fibrosis  
Loss of normal liver architecture  
Nodular appearance  
Grade: degree of inflammation  
Stage: degree of architectural distortion (from mild portal fibrosis to cirrhosis)

Question 15

What imaging should be performed in cirrhosis?

Answer 15

US, CT or MRI: to detect Ascites, HCC, Hepatic or portal vein thrombosis + Exclude biliary obstruction
MRCP (if PSC suspected)

Question 16

What may be found on endoscopy in cirrhosis?

Answer 16

Varices

Portal hypertensive gastropathy

Question 17

What grading system is used to estimate prognosis in cirrhosis?

Answer 17

Child-Pugh Grading A-C: based on 5 factors: 
Albumin  
BR
PT 
Ascites  
Encephalopathy

Question 18

How is cirrhosis managed?

Answer 18

Treat the CAUSE if possible  
Avoid alcohol, sedatives, opiates, NSAIDs + drugs that affect the liver  
Nutrition is important  
Enteral supplements should be given  
NG feeding may be indicated

Question 19

How is encephalopathy treated?

Answer 19

Treat infections
Exclude GI bleed
Use lactulose + phosphate enemas
Avoid sedation

Question 20

How is ascites treated?

Answer 20

Diuretics (spironolactone +/- furosemide)
Dietary sodium restriction
Therapeutic paracentesis (with human albumin replacement)
Monitor weight
Fluid restrict if plasma Na+ < 120 mmol/L
Avoid alcohol + NSAIDs

Question 21

How is SBP treated?

Answer 21

Abx (e.g. cefuroxime + metronidazole)

Prophylaxis against recurrent SBP with ciprofloxacin

Question 22

What surgical intervention may be used in cirrhosis to reduce portal HTN? What is the issue with this?

Answer 22

TIPS (transjugular intrahepatic portosystemic shunt) to reduce portal HTN
May precipitate encephalopathy as provides a route for blood from GIT to bypass the liver

Question 23

List 7 complications of cirrhosis

Answer 23

Portal HTN with ascites  
Hepatic encephalopathy 
Variceal haemorrhage  
SBP 
HCC 
Renal failure (hepatorenal syndrome)  
Pulmonary HTN (hepatopulmonary syndrome)

Question 24

What is the prognosis in cirrhosis?

Answer 24

Depends on aetiology + complications
Generally poor prognosis
Overall 5 year survival = 50%
If ascites, 2 year survival = 50%

Question 25

List 5 inherited diseases that can lead to cirrhosis

Answer 25

a1-antitrypsin deficiency
Haemochromatosis
Wilson's disease
Galactosaemia
Cystic Fibrosis

Question 26

List 6 risk factors for NASH

Answer 26

Obesity
Diabetes
Total parenteral nutrition
Short bowel syndromes
Hyperlipidaemia
Drugs (e.g. amiodarone, tamoxifen)

Question 27

What investigations can be used to determine the cause of cirrhosis?

Answer 27

Viral serology (hep B + C)
a1-antitrypsin  
Caeruloplasmin (LOW in Wilson's)  
Iron studies: serum ferritin, iron, total iron binding capacity (TIBC): for haemochromatosis 
Anti-mitochondrial antibody (PBC) 
ANA
SMA (AI hepatitis)

Question 28

How does encephalopathy arise in cirrhosis? How does lactulose treat this?

Answer 28

Normal liver breaks down ammonia absorbed in GIT
In Cirrhosis, ammonia goes through liver without being broken down + exerts toxic effects on the brain
Lactulose reduces absorption of ammonia from gut
Helps prevent encephalopathy caused by ammonia reaching the brain

Question 29

What is the only curative method for cirrhosis?

Answer 29

Liver transplant