Cirrhosis

Question 1

What is cirrhosis.

Answer 1

Necrosis of hepatic parenchyma with connective tissue proliferation and nodular regeneration.
This causes the liver architecture to be vastly abnormal and produces the clinical features of portal hypertension and impaired liver cell function.
It implies irreversible liver damage.

Question 2

What are the causes of cirrhosis. (16)

Answer 2

There are many causes of cirrhosis. The most common is chronic alcohol abuse. (in the west)
Other causes include:
Hepatitis B/C/D (most common worldwide)
Non- alcoholic fatty liver disease. 
Biliary cirrhosis (primary/secondary).
Autoimmune hepatitis. 
Hereditary haemochromatosis. 
Hepatic venous congestion. 
Budd-Chiari syndrome. 
Wilson's disease. 
Drugs (eg methotrexate).
a1-antitrypsin deficiency. 
Cystic fibrosis. 
Galactosaemia. 
Glycogen storage disease, 
Veno-occlusive disease. 
Idiopathic. (cryptogenic).

Question 3

What are the complications caused by cirrhosis. (4)

Answer 3

Portal hypertension.
Impaired liver function.
Hepatic failure.
Hepatocellular carcinoma.

Question 4

Fibrosis is initiated by _______

Answer 4

Stellate cells.

Question 5

What are the characteristic pathological features of cirrhosis. (2)

Answer 5

Regenerating nodules separated by fibrous septa.

Loss of the normal lobular architecture within the nodules.

Question 6

What are the two brad types of cirrhosis.

Answer 6

Micronodular cirrhosis.

Macronodular cirrhosis.

Question 7

What are the features of micronodular cirrhosis. (2)

Answer 7

Regenerating nodules are usually

Question 8

What is micronodular cirrhosis caused by. (2)

Answer 8

Chronic alcohol misuse or biliary tract disease.

Question 9

What are the features of macronodular cirrhosis. (2)

Answer 9

The nodules are of variable size.

Normal acini may be seen within the larger nodules.

Question 10

What is macronodular cirrhosis usually caused by.

Answer 10

Often seen following chronic viral hepatitis.

Question 11

What are the signs of cirrhosis. (34)

Answer 11

These are related to the underlying cause: 
Lethargy. 
Hepatomegaly. 
Splenomegaly.
Jaundice. 
Leuconychia. 
Telangiectasia. 
Spider naevi. 
Cyanosis. 
Bruises. 
Purpura. 
Epistaxis. 
Gynacomastia (in men).
Xanthelasma/xanthoma. 
Dupuytren's contracture. 
Clubbing. 
Dilated chest/abdominal wall veins (caput medusae).
Scratch marks. 
Parotid enlargement. 
Collateral vessels. 
Variceal bleeding. 
Encephalopathy. 
Pigmentation changes. 
Loss of libido. 
Testicular atrophy. 
Impotence. 
Breast atrophy (in women).
Irregular menses. 
Amenorrhoea. 
Fetor hepaticus. 
Palmar erythema. 
Terry's nails. 
Kayser-Fleischer rings. 
Tattoos. 
IV tract marks.

Question 12

What is the Child-Pugh scoring system for cirrhosis.

Answer 12

It is used to predict the prognosis of cirrhotic patients.

Question 13

What areas does the Child-Pugh score take into consideration (5)

Answer 13

Albumin. 
Bilirubin. 
INR.
Ascites. 
Encephalopathy.

Question 14

What are the complications of cirrhosis. (9)

Answer 14

1. Malnutrition. - Catabolism, reduced glycogenolysis and increased gluconeogenesis, hypoglycaemia/impaired glucose tolerance.
2. Hepatic encephalopathy - caused by infection, constipation, drugs/toxins, GI bleed, electrolyte disturbances = affects conscious levels, behaviour and intellectual function.
3. Ascietes/oedema - caused by portal hypertension, hypoalbuminaemia and increased capillary permeability leading to fluid seepage, with stimulation of the renin-angiotensin system = abdominal distention, breathlessness with gross ascites, pleural effusions and peripheral oedema.
4. Vitamin deficiency - typically B vitamins (especially thiamine)
5. Coagulopathy.
6. Impaired immune system.
7. Varices - portal hypertension leads to the formation of collateral circulations - oesophagus, umbilical and rectal. These can bleed.
8. Hepatorenal syndrome - renal failure in the presence of severe liver disease, where all other causes have been excluded.
9. Hepatocellular carcinoma (HCC) - cirrhosis is found in 65-90% of patients with HCC.

Question 15

Who gets cirrhosis.

Answer 15

It can occur at any age.

It can occur to men and women equally, although the incidence of cirrhosis in women is increasing.

Question 16

Where are the stellate cells located in the liver.

Answer 16

In the space of Disse.

Question 17

How are stellate cells activated.

Answer 17

By cytokines produced by Kupffer cells and hepatocytes. (following liver injury)

Question 18

How do stellate cells cause damage to the liver.

Answer 18

After becoming activated by cytokines, they are transformed into a myofibroblast-like cell, capable of producing collagen, pro-inflammatory mediators and other mediators that promote hepatocyte damage and tissue fibrosis.

Question 19

How is cirrhosis diagnosed.

Answer 19

Histologically.

Question 20

What are the initial symptoms of cirrhosis. (10)

Answer 20

It is highly variable. 
Some patients are asymptomatic and the diagnosis is made incidentally at US or surgery. 
Symptoms are usually non-specific, and include:
Weakness. 
Fatigue. 
Muscle cramps. 
Weight loss. 
Anorexia. 
Nausea. 
Vomiting. 
RUQ pain. 
It may occasionally present with shortness of breath(due to large R pleural effusion) or with hepatopulmonary syndrome.

Question 21

When is hepatomegaly usually found in patients presenting with cirrhosis. (2)

Answer 21

When the cirrhosis is due to:
Alcoholic Liver Disease.
Haemochromatosis.

Progressive hepatocyte damage abnd fibrosis gradually reduces the liver size in other causes.

Question 22

What does the liver feel like on physical exam in cirrhosis. (3)

Answer 22

Hard.
Irregular.
Non-tender.

Question 23

What are three common physical findings in patients presenting with alcoholic cirrhosis.

Answer 23

Spider telangiectasia.
Gynacomastia.
Parotid enlargement.

Question 24

What is a prominent physical finding in haemochromatosis.

Answer 24

Pigmentation.

Question 25

What is a drug induced caused of gynacomastia in men.

Answer 25

Spironolactone.

Question 26

Is bruising an early or late sign of liver cirrhosis.

Answer 26

A late sign.

Question 27

What do the phrases ‘hepatic decompensation’ and ‘hepatic liver disease’ mean.

Answer 27

They are used to describe chronic liver failure.

Question 28

Hepatic failure is a complication of cirrhosis, what clinical features are present. (7)

Answer 28

Coagulopathy.
Encephalopathy (ie liver flap - asterixis).
Confusion/coma.
Hypoalbuminaemia (oedema, leuconychia).
Sepsis (pneumonia, septicaemia).
Spontaneous bacterial peritonitis (SBP).
Hypoglycaemia.

Question 29

Portal hypertension is a complication of cirrhosis. What are the clinical features.

Answer 29

Ascites.
Splenomegaly.
Portosystemic shunt (including oesophageal varices).
Caput medusa.

Question 30

What does coagulopathy due to hepatic failure show on blood test. (5)

Answer 30

Decrease in factors 2, 7, 9 and 10.

Increase in INR.