Cirrhosis Flashcards
what is it?
chronic liver damage with replacement of normal liver architecture with diffuse fibrosis
Cirrhosis is considered DECOMPENSATED when?
if becomes complicated by any of GAJE;
GI bleed
Ascites
Jaundice
Encephalopathy
Aetiology/Risk factors?
Chronic alcohol misuse (most common in the UK)
Chronic viral hepatitis (hep B/C - most common worldwide)
Autoimmune hepatitis
Drugs (e.g. methotrexate, hepatotoxic drugs)
Inherited; a1-antitrypsin deficiency Haemochromatosis Wilson's disease Galactosaemia Cystic Fibrosis
Vascular ;
Budd-Chiari Syndrome
Hepatic Venous Congestion
Chronic Biliary Diseases;
Biliary atresia
Unknown: 5-10%
Non-Alcoholic Steatohepatitis (NASH) ;
Associated with obesity, diabetes, total parenteral nutrition, hyperlipidaemia
Presenting symptoms?
Early non-specific symptoms:
Anorexia Nausea Fatigue Weakness Weight loss
Symptoms due to decreased liver synthetic function:
Easy bruising
Abnormal swelling
Ankle oedema
Symptoms due to reduced detoxification function: Jaundice Personality change Altered sleep pattern Amenorrhoea Galactorrhoea
Symptoms due to portal hypertension:
Abdominal swelling
Haematemesis
PR bleeding or melaena
signs of any chronic liver disease?
ABCD; Asterixis Ascites Bruises Clubbing Dupuytren's contracture
Palmar erythema
Jaundice
Gynaecomastia
Leukonychia
Parotid enlargement
Spider naevi
Scratch mark (from cholestatic pruritis)
Enlarged liver (may be shrunken in the later stages)
Testicular atrophy
Caput medusae
Splenomegaly
Ivx?
FBC: low platelets + Hb = because of hypersplenism as a result of portal hypertension
LFTs - may be normal but often get:
High AST, ALT, ALP, GGT and bilirubin
Low albumin
Low Na
Clotting: prolonged PT
Serum AFP (alpha-fetoprotein = tumour marker for liver cancer):
Raised in chronic liver disease
High levels may suggest hepatocellular carcinoma
invx to determine cause; viral serology etc
Ascitic tap; IMPORTANT: ascitic tap with neutrophils > 250/mm3 = spontaneous bacterial peritonitis (SBP)
abdo US, CT, MRI
What is the Child-Pugh grading system?
Child-Pugh Grading - score for estimating the prognosis in chronic liver disease/cirrhosis. It is based on 5 factors:
Albumin Bilirubin PT Ascites Encephalopathy
Cirrhosis can be divided into Classes using the Child-Push grading system:
Class A: 5-6
Class B: 7-9
Class C: 10-15
Management of cirrhosis?
1st - Treat underlying cause;
- whether hep A or haemochromatosis etc
- sodium restriction + diuretics for ascites
- avoid, alcohol, opiates, nsaids drugs affecting liver
2nd line; liver transplant
encephalopathy
- Use lactulose and phosphate enemas
- lactulose reduces the absorption of ammonia from the gut
- helps prevent encephalopathy caused by ammonia reaching the brain
ascites ivx and mx management?
Initially:
Diagnostic paracentesis; take sample for cultures and biochemistry (albumin, amylase, bnp, ADA)
Calculate the Serum ascitic albumin gradient - SAAG
Give prophylactic antibiotics if GI bleeding present.
————————- Treatment:
Mainstay 1+2:
1. Diuretics (spironolactone with/without furosemide)
- Dietary sodium restriction
Monitor weight
Fluid restrict if plasma sodium < 120 mmol/L.
Give abx if SBP
Monitoring:
There is a risk of hyponatraemia so stop diuretics if this happens
Avoid alcohol and NSAIDs
causes of ascites?
Other causes of portal hypertension that may be associated with ascites include congestive heart failure, constrictive pericarditis, alcoholic liver disease, fulminant hepatitis, subacute hepatitis, massive liver metastasis, and Budd-Chiari syndrome.
Conditions causing hypo-albuminaemia such as nephrotic syndrome and protein-losing enteropathy may result in ascites. Peritoneal diseases including infectious peritonitis and malignancies can also cause ascites.
How does SAAG help to narrow differentials of ascites?
SAAG ≥11 /L (or 1.1mg/dL) Portal hypertension: Cirrhosis Cardiac failure Portal vein thrombosis* Hypothyroidism*
SAAG <11 /L Peritoneal carcinomatosis Peritoneal tuberculosis Pancreatitis* Bowel perforation* Nephrotic syndrome*
How is refractory ascites treated?
As the liver disease progresses the ascites may no longer respond to medication. This is known as untreatable or refractory ascites.
They will have:
- Therapeutic paracentesis (with human albumin replacement)
- so drainage every few weeks in the hospital
Last line:
- TIPSS - transjugular intrahepatic portosystemic shunt
- placing a small tube (stent) in the liver
purpose for SAAG?
calculation?
SAAG = (serum albumin) − (albumin level of ascitic fluid).
Tells us whether the ascites is due to high oncotic pressure or hydrostatic pressure?
high saag means higher albumin in serum so hydrostatic pressure imbalance hence fluid being pushed out of circulation.
what are major factors in pathogenesis of ascites in cirrhosis?
Sodium retention is a major factor in pathogenesis
And water retention
due to activation of the RAS and sympathetic NS causing release of ADH
