CIRRHOSIS

Question 1

Definition (2)

Answer 1

• Necrosis of liver cells followed by fibrosis and nodule formation
• End result is impairment of liver cell function and gross distortion of the liver architecture leading to portal hypertension

Question 2

Causes (4)

Answer 2

1- Hepatitis B and C (most common causes worldwide)
2- Alcohol (most common cause in western world)
3- NAFLD
4- Other causes: PBC, PSC, autoimmune hepatitis, hemochromatosis, Budd-Chiari, Wilson’s, a1-antitrypsin, CF, metabolic storage diseases, drugs, cryptogenic

Question 3

Pathology (2)

Answer 3

• Micronodular cirrhosis: uniform, small nodules up to 3mm in diameter. This type is often caused by ongoing alcohol damage or biliary tract disease
• Macronodular cirrhosis: nodules of variable size and normal acini may be seen within large nodules. This type is often seen following chronic viral hepatitis

Question 4

Clinical Features (4)

Answer 4

1- Are secondary to portal hypertension and liver cell failure
2- Cirrhosis with complications (encephalopathy, ascites, or varicella hemorrhage) is called decompensated cirrhosis
3- Cirrhosis without any of these is called compensated cirrhosis
4- May present with bacteremia, infections, malnutrition, osteoporosis

Question 5

Investigations (9)

Answer 5

1- CBC: thrombocytopenia at diagnosis; leukopenia and anemia developing later
2- LFTs: slight elevation of serum alkaline phosphotase and aminotransferases
3- Prothrombin time and serum albumin are best indicators of liver function
4- Serum electrolytes: low sodium concentration indicates severe liver disease secondary to either impaired free water clearance or excess diuretic therapy
5- Elevated serum creatinine associated with worse prognosis
6- Serum a-fetoprotein (AFP): may be high (normally undetectable). If level greater than 200 ng/mL —> strongly suggestive of presence of and HCC
7- Endoscopy to look for esophageal varices (primary prophylaxis offered to decrease bleeding)
8- US: detection of HCC and assess patency of portal and hepatic veins
9- A dual energy x-ray absorptiometry (DXA) scan performed for osteoporosis

Question 6

Management (5)

Answer 6

1- Managment of complications
2- Correcting underlying cause (e.g. venesection for hemochromatosis, abstinence from alcohol for alcoholic cirrhosis)
3- Screening for HCC (measurement of serum AFP and US every 6 months)
4- Liver transplantation in patients with end-stage cirrhosis
5- Patients offered influenza immunization

Question 7

Prognosis (2)

Answer 7

1- The severity and prognosis of liver disease can be graded according to:
- Modified Child-Pugh classification to assess hepatic reserve; depends on:
- Encephalopathy
- Ascites
- Prothrombin time
- Serum bilirubin
- Albumin
- MELD score (modification of end-stage liver disease dependent on serum bilirubin, creatinine, and the international normalized ratio (INR) and age)
2- Overall, the 5 year survival rate is approx 50%