Cirrhosis

Question 1

What is the definition of cirrhosis?

Answer 1

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

Decompensated when there are complications such as ascites, jaundice, encephalopathy or GI bleeding.

Question 2

Describe the risk factors associated with liver cirrhosis.

Answer 2

Chronic alcohol misuse: Most common UK cause.

Chronic viral hepatitis: Hepatitis B/C are the most common causes worldwide.

Autoimmune hepatitis.

Drugs: e.g. methotrexate, hepatotoxic drugs.

Inherited: a1-Antitrypsin deficiency, haemochromatosis, Wilson’s disease, galactosaemia,
cystic fibrosis.

Vascular: Budd–Chiari syndrome or hepatic venous congestion.

Chronic biliary diseases: Primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), biliary atresia.

Cryptogenic: In 5–10%.

Non-alcoholic steatohepatitis (NASH) ⬆️ risk of developing cirrhosis. NASH is associated with obesity, diabetes, total parenteral nutrition, short bowel syndromes, hyperlipidaemia and drugs, e.g. amiodarone, tamoxifen.

Decompensation can be precipitated by infection, GI bleeding, constipation, high-protein meal, electrolyte imbalances, alcohol and drugs, tumour development or portal vein thrombosis.

Question 3

Describe the epidemiology of liver cirrhosis.

Answer 3

One of the most common causes of death worldwide

Question 4

What would a patient with cirrhosis complain of in their history?

Answer 4

Early non-specific symptoms:
Anorexia, nausea, fatigue, weakness, weight loss.

Symptoms caused by ⬇️ liver synthetic function:
Easy bruising, abdominal swelling, ankle oedema.

Reduced detoxification function:
Jaundice, personality change, altered sleep pattern, amenorrhoea.

Portal hypertension:
Abdominal swelling, haematemesis, PR bleeding or melaena.

Question 5

Describe what would be found on examination of a patient with liver cirrhosis.

Answer 5

Stigmata of chronic liver disease: (ABCDE)
•Asterixis (‘liver flap’). 
•Bruises. 
•Clubbing. 
•Dupuytren’s contracture. 
•Erythema (palmar). 

• Jaundice,
• gynaecomastia,
• leukonychia,
• parotid enlargement,
• spider naevi,
• scratch marks,
• ascites (‘shifting dullness’ and fluid thrill),
• enlarged liver (shrunken and small in later stage),
• testicular atrophy,
• caput medusae (dilated superficial abdominal veins),
• splenomegaly (indicating portal hypertension).

Question 6

What investigations would you perform for a patient with suspected liver cirrhosis?

Answer 6

Blood:
•FBC: ⬇️ Hb, ⬇️ platelets as a result of hypersplenism.
•LFTs: May be normal or often ⬆️ transaminases, AlkPhos, GGT, bilirubin, ⬇️ albumin.
•Clotting: Prolonged PT (⬇️ synthesis of clotting factors).
•Serum AFP: ⬆️ In chronic liver disease, but high levels may suggest hepatocellular carcinoma.

Other investigations:
•To determine the cause,
—e.g. viral serology (HBsAg, HBsAb, HCV ab), a1-antitrypsin, caeruloplasmin (Wilson’s disease),

iron studies:
•serum ferritin,
•iron,
•total iron binding capacity (haemochromatosis),
•antimitochondrial antibody (PBC),
•antinuclear antibodies (ANA),
•SMA (autoimmune hepatitis).

Ascitic tap:
•Microscopy, culture and sensitivity, biochemistry (protein, albumin, glucose, amylase) and cytology.
—If neutrophils >250/mm3, this indicates spontaneous bacterial peritonitis (SBP).

Liver biopsy:
Percutaneous or transjugular if clotting deranged or ascites present.

Histopathology:
•Periportal fibrosis, loss of normal liver architecture and nodular appearance.
—Grade refers to the assessment of degree of inflammation,
—whereas stage refers to the degree of architectural distortion, ranging from mild portal fibrosis to cirrhosis.

Imaging: 
•Ultrasound, 
•CT or MRI 
—(to detect complications of cirrhosis such as ascites, hepatocellular carcinoma, and hepatic or portal vein thrombosis, to exclude biliary obstruction), 
•MRCP (if PSC suspected).

Endoscopy:
•Examine for varices, portal hypertensive gastropathy.

Child–Pugh grading:
•Class A is score 5–6, Class B is score 7–9, Class C is score 10–15.

Question 6

How would you manage a patient with liver cirrhosis?
•encephalopathy 
•ascites
•Spontaneous Bacterial Peritonitis (SBP)
•surgical options.

Answer 6

Treat the cause if possible,
•avoid alcohol, sedatives, opiates, NSAIDs and drugs that affect the liver.

Nutrition is very important and if intake is poor, dietitian review and enteral supplements should be given;
—nasogastric feeding may be indicated.

Treat the complications:
•Encephalopathy:
—Treat infections.
—Exclude a GI bleed.
—Lactulose, phosphate enemas
—avoid sedation.

Ascites:
•Diuretics (spironolactone+/-furosemide),
•dietary sodium restriction (88meq or 2g/day),
•therapeutic paracentesis (with human albumin replacement IV).
•Monitor weight daily.
•Fluid restriction in patients with plasma sodium

Question 7

Describe the complications associated with liver cirrhosis.

Answer 7

• Portal hypertension with ascites,
• encephalopathy
• variceal haemorrhage,
• SBP,
• hepatocellular carcinoma.
• Renal failure (hepatorenal syndrome).
• Pulmonary hypertension (hepatopulmonary syndrome).

Question 8

What is the prognosis for a patient with liver cirrhosis?

Answer 8

Depends on the aetiology and complications.

Generally poor;
•overall 5-year survival is ~50%.
•In the presence of ascites, 2-year survival of ~50%.