Cirrhosis Flashcards
What is Cirrhosis?
Cirrhosis = end-stage of chronic liver damage, characterised by replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes
Decompensation = complications occur (ascites, jaundice, encephalopathy, GI bleeding)
What is the aetiology of cirrhosis?
Many causes VITAMIN IDCE
Alcoholic hepatitis - chronic alcohol misuse (Most common UK cause)
NASH (Non-alcoholic steatohepatitis)
Chronic viral hepatitis (Hep B/C most common causes worldwide)
Autoimmune hepatitis
Drugs - E.g. methotrexate
Inherited - Alpha-1-antitrypsin deficiency, haemochromatosis, Wilson’s
Vascular - Budd-Chiari syndrome
Chronic biliary diseases - Primary biliary cirrhosis, primary sclerosing cholangitis
Cryptogenic aka unknown (5-10%)
Decompensation can be triggered by: Infection, GI bleeding, constipation, high-protein meal, electrolyte imbalances
What are the risk factors of cirrhosis?
Chronic excessive alcohol misuse
IVDU - Increased Hep B/C risk
Unprotected intercourse - Increased Hep B/C risk
Obesity - NASH
Blood transfusion
Tattooing
What is the epidemiology of cirrhosis
Among the top 10 leading cause of deaths worldwide
More common in men
NASH is increasing in prevalence (due to increased epidemics of obesity)
Now the most common cause of liver transplants in UK
What are the symptoms of cirrhosis?
Compensated symptoms Early non-specific symptoms = FLAWS Anorexia Nausea Fatigue and weakness Weight loss
Decompensated symptoms Reduced liver synthetic function Easy bruising Abdominal swelling Ankle oedema
Reduced detoxification function Jaundice Altered sleep pattern Amenorrhoea Pruritus Hepatic encephalitis
Portal hypertension
Ascites - abdominal swelling
Hematemesis – oesophageal varices
PR bleeding/melena – oesophageal varices
What are the signs of cirrhosis?
ABCDEFG of chronic liver disease stigmata: • Asterixis • Bruise • Clubbing • Dupuytren’s contracture • Erythema • Fetor hepaticus • Gynaecomastia
Hand signs
• Leukonychia
• Palmar erythema
• Spider nevi
Facial signs • Telangiectasia • Spider nevi • Jaundiced sclera • Parotid enlargement • Hepatic fetor (bad breath)
Abdominal signs • Hepatosplenomegaly • Distention • Caput medusa (distended superficial abdominal veins) • Shifting dullness • Gynaecomastia
Also: Personality changes/altered mental status
What are appropriate investigations for cirrhosis?
Bloods
LFTs: Deranged LFTs
AST/ALT levels increase
Total bilirubin generally rises with progressive cirrhosis
Elevated GGT (gamma-glutamyl transferase)
Serum albumin: Reduced
Electrolytes: Reduced sodium
Clotting: Prolonged PT – most sensitive for liver failure
FBC: Thrombocytopenia, anaemia
Serum AFP: Increased
Immunology: anti-hep C Abs, hep-B antigen
Other investigations
CAUSE -Bloods
Serum caeruloplasmin: LOW in Wilson’s disease
ANA and anti-SM Ab: Autoimmune hepatitis
Alpha-1 antitrypsin: Reduced in deficiency
PROGNOSIS - Imaging = US/CT/MRI Liver surface nodularity Small liver (cirrhotic) Ascites HCC = hepatocellular carcinoma Hepatic thrombosis
COMPLICATIONS - Upper GI endoscopy
Varices, portal hypertensive gastropathy
GOLD STANDARD DIAGNOSIS - Liver biopsy and histology - > Periportal fibrosis, loss of normal liver architecture, nodular appearance (regenerating hepatocytes), fatty changes, scarring around nodules
Diffuse changes
How can cirrhosis be managed?
Treat cause if possible
Hep C: Oral direct-acting antiviral agents
Avoid agents that affect the liver - Alcohol, sedatives, opiates, NSAIDs
Nutrition Dietician and enteral supplements if poor intake
Treat complications:
Encephalopathy - Treat infections, Exclude GI bleed,
Lactulose, Phosphate enemas
Ascites- Diuretics: spironolactone +/- frusemide
Dietary sodium restriction
Therapeutic Paracentesis with human albumin replacement IV
Daily weight monitoring
Fluid restriction (Na<120)
Avoid alcohol and NSAIDs
Spontaneous bacterial peritonitis - ABs: cefuroxime, metronidazole, Bacteria: e.coli, klebsiella
Portal hypertensionv - TIPS insertion
May precipitate encephalopathy
Liver transplantation - Referral should be made without delay in all decompensated patients
What are possible complications of cirrhosis
Ascites Gastro-oesophageal varices Variceal haemorrhage Hepatocellular carcinoma SBP = spontaneous bacterial peritonitis Portal hypertension Hepatic hydrothorax Encephalopathy Hepatorenal syndrome = RF Hepatopulmonary syndrome = pulmonary hypertension
What is the prognosis of cirrhosis?
Depends on aetiology and complications, but generally poor
Likelihood of transitioning from compensated to decompensated within 10 years = 50%
Overall 5-year survival = 50%
2-year survival with ascites = 50%
How can cirrhosis prognosis be tested?
PROGNOSIS - Ascitic tap
Look for SBP – spontaneous bacterial peritonitis
MC+S, biochemistry (protein/albumin/amylase) and cytology
PROGNOSIS - Child-Pugh grading
Assesses prognosis, severity of disease and necessity of liver transplantation
Looks at: albumin, bilirubin, PT, ascites and encephalopathy
