Cirrhosis Flashcards
What is cirrhosis?
Cirrhosis is defined anatomically by the presence throughout the liver of fibrous septa that subdivide the parenchyma into nodules.
What are causes of cirrhosis?
- Chronic alcohol abuse
- HBV
- HCV
- Haemochromatosis
- A1-antitrypsin
- Wilson’s disease
- Budd-chiari
- Wilson’s disease
- Cystic fibrosis
- Non-alcoholic steatohepatitis
- PSC, PBC
- Autoimmune hepatitis
- Drugs - amiodarone, methyldopa, methotrexate
What are signs of liver cirrhosis?
- Leuconychia
- Terry’s nails
- Clubbing
- Palmar erythema
- Hyperdynamic circulation
- Dupuytren’s contracture
- Spider naevi
- Xanthelasma
- Gynaecomastia
- Atrophic testes
- Loss of body hair
- Parotid enlargement
- Hepatomegaly
- Small liver - late disease
- Ascites
- Splenomegaly
What are symptoms of liver cirrhosis?
- Right hypochondrial pain due to liver distension
- Altered mental status
- Pruritis
- Fatigue/Weakness
- Weight loss
- Abdominal distention
- Haematemesis/malaena
- Leg swelling
- Gynaecomastia
- Loss of libido
- Amenorrhoea
What are complications of liver cirrhosis?
- Hepatic failure
- Portal hypertension
- Ascites
- Spontaneous bacterial peritonitis
- Enchephalopathy
- Renal failure
- HCC
What are risk factors for the development of cirrhosis?
- Alcohol misuse
- IVDU
- Unprotected intercourse
- Obesity
- Blood transfusion
- Tatooing
What is the pathogenesis of cirrhosis?
Chronic injury to the liver results in inflammation, necrosis and, eventually, fibrosis Fibrosis is initiated by activation of the stellate cells. Kupffer cells, damaged hepatocytes and activated platelets are probably involved.
What are the pathological features of cirrhosis?
Characteristic features of cirrhosis are regenerating nodules separated by fibrous septa and loss of the normal lobular architecture within the nodules
What are pathological features of micronodular cirrhosis?
Regenerating nodules are usually <3 mm in size and the liver is involved uniformly
What are causes of micronodular cirrhosis?
- Alcohol misuse
- Biliary tract disease
What are pathological features of macronodular cirrhosis?
The nodules are of variable size and normal acini may be seen within the larger nodules
What is often the cause of macronodular cirrhosis?
Chronic viral hepatitis
What are features of hepatic failure?
- Coagulopathy
- Encephalopathy
- Hypoalbuminaemia
- Sepsis
- Spontaneous bacterial peritonitis
- Hypoglycaemia
What are features of portal hypertension in someone with cirrhosis?
- Ascites
- Splenomegaly
- Portosystemic shunt - including oesophageal varices
- Caput medusae
What investigations would you consider doing in someone you suspected had liver cirrhosis?
-
Bloods
- LFT, FBC, Clotting, Albumin, glucose
- Find the cause - hepatitis serology, iron studies, immunoglobulins, autoantibodies, A-fetoprotein, copper + caeruloplasmin (<40 yrs), A1-antitrypsin
- Liver US + duplex
- MRI
- Ascitic tap
- Consider endoscopy
- Liver biopsy
What might you see on LFT in someone with cirrhosis?
Normal LFTs, or
- Increased Bilirubin
- Increased AST
- Increased ALT
- Increased ALP
- Increased GGT
When would synthetic dysfunction of the liver (i.e. albumin production, clotting factors) occur in cirrhosis?
Late feature of cirrhosis
What might you see on FBC in someone with cirrhosis?
Features of hyposplenism
- Decreased WCC
- Thrombocytopenia
What autoantibodies would you be looking for in someone with suspected cirrhosis?
- ANA
- AMA
- SMA
What might you find on Liver US + duplex scan?
- Small liver/Hepatomegaly
- Splenomegaly
- Focal liver lesions
- Hepatic vein thrombosis
- Reversed flow in portal vein
- Ascites
What might you see on MRI in someone with suspected cirrhosis?
- Increased caudate lobe size
- Smaller islands of regenerating nodules
Why might you do iron studies in someoen with suspected cirrhosis?
Look for hereditary haemochromatosis
What might you see on U+E’s in someone with cirrhosis?
Hyponatraemia - indicates severe liver disease due to defect in free water clearence/excess diuretic therapy
What can a raised A-fetoprotein (>200 ng/mL) indicate in someone with cirrhosis?
Hepatocellular carcinoma
What might a raised copper and low caeruloplasmin indicate?
Wilson’s disease as cause of cirrhosis
What are indications for liver transplant in someone with cirrhosis?
- Acute liver failure
- Advanced cirrhosis
- Hepatocellular cancer
Why might you consider doing endoscopy in someone with cirrhosis?
Detection and treatment of:
- Oesophageal varices
- Portal hypertensive gastropathy
What is involved in a ascitic tap?
Aspiration of ascitic fluid
Why does ascites occur in cirrhosis?
- Sodium and water retention - peripheral arterial vasodilatation and consequent reduction in the effective blood volume
- Portal hypertension - local hydrostatic pressure and leads to increased hepatic and splanchnic production of lymph and transudation
- Low serum albumin - reduction in plasma oncotic pressure.
What investigations would you perform on ascitic fluid?
- Cell count
- Gram stain and culture
- Serum ascites-albumin gradient
- Cytology
- SAAG
What would a serum ascites-albumin gradeint of > 1.1g/dl indicate as the cause of ascites?
Portal HTN related
- Portal hypertension
- CHF
- Constrictive pericarditis
- Budd Chiarri
- Myxedema
- Massive liver metastases
What would a serum ascites-albumin gradeint of < 1.1g/dl indicate as the cause of ascites?
Non-portal HTN related
- Malignancy
- Tuberculosis
- Chylous ascites
- Pancreatic
- Biliary ascites
- Nephrotic syndrome
- Serositis
How would you generally manage someone with cirrhosis?
- Specific treatment for cause
- Good nutrition
- Alcohol abstinence
- Avoid NSAIDs, sedatives, and opiates
- Consider HCC monitoring - A-fetoprotein + ultrasound
How would you manage someone with ascites as a complication of liver cirrhosis?
- Fluid restriction <1.5 L/day
- Low salt diet
- Spironolactone
- Monitor weight
- Consider diuretics if poor response
- Consider therapeutic paracentesis
What do you need to consider in someone with ascites who deteriorates suddenly?
Spontaneous bacterial peritonitis
What are common organisms implicated in spontaneous bacterial peritonitis?
- E. Coli
- Klebsiella
- Streptococci
What investigations sould you consider doing if you suspected spontaneous bacterial peritonitis?
Paracentesis
How would you manage someone with spontaneous bacterial peritonitis?
- Antibiotics - Pip/Taz until sensitivities known
- Ascitic fluid drainage
What are features of grade 1 hepatic encephalopathy?
- Sleep reversal
- Altered mood/behaviour
- Mild lack of awareness/Shortened attention span
- Impaired computations
- Dyspraxia - 5 point star
What are features of grade II hepatic encephalopathy?
- Increasing drowsiness/lethargy
- Confusion
- Slurred speech
- May have liver flap
- Personality change
What are features of grade III hepatic encephalopathy?
- Somnolence/Stuporous
- Confusion/disorientation/Incoherent
- Restless
- Asterixis
- Hyperreflexia
- Nystagmus
- Clonus
- Rigidity
What are features of grade IV hepatic encephalopathy?
Coma
How does hepatic encephalopathy occur?
As liver fails, nitrogenous waste builds up in the circulation and passes into the brain, where astrocytes clear it (by processes involving the conversion of glutamate to glutamine).
Excess glutamine causes an osmotic imbalance and a shift of fluid into these cells, leading to cerebral oedema
How would you manage hepatic encephalopathy as a complication of acute/decompensated liver failure?
- 20o head-up tilt in ITU
- Avoid sedatives
- Correct electrolytes
- Lactulose
- Rifaximin
Why might you use lactulose in someone with hepatic encephalopathy?
It is catabolised by bacterial flora to short chain fatty acids which decrease colonic pH and trap NH3 in the colon as NH4+
Why might you use Rifaximin in management of hepatic encephalopathy?
Non-absorbable antibiotic that decreases numbers of nitrogen forming bacteria in the gut
What factors can increase the risk decompensated lvier failure in someone with cirrhosis?
- Dehydration
- Constipation
- Covert alcohol use
- Infection
- Opiate overuse
- Occult GI bleed
- Portal vein thrombosis
What are pre-hepatic causes of portal hypertension?
Portal venous thrombosis
What are intrahepatic causes of portal hypertension?
- Schistosomiasis
- Sarcoidosis
- PBC
- Cirrhosis
- Veno-occlusive disease
- Budd chiari syndrome
What are post-hepatic causes of portal hypertension?
- Right heart failure
- Constrictive pericarditis
- IV obstruction
How would you manage a varcieal bleed?
- IV Terlipressin
- Broad-spectrum IV antibiotics
- Endotherapy - variceal ligation/Sclerotherapy
- Correct any coagulopathies
What can be used to control uncontrolled variceal bleeding?
- Trans-jugular intrahepatic porto-systemic shunt (TIPS)
- Balloon tamponade - Sengstaken-Blakemore tube - compresses the varcies
What is the SAAG?
The serum-ascites albumin gradient or gap (SAAG) is a calculation used in medicine to help determine the cause of ascites. The SAAG may be a better discriminant than the older method of classifyingascites fluid as a transudate versus exudate
