Cirrhosis

Question 1

What is cirrhosis?

Answer 1

Cirrhosis can derive from any chronic liver disease.
Diffuse transformation of the entire liver into regenerative parenchymal nodules surrounded by fibrous bands.
Cirrhosis accounts for most liver-related deaths.

Question 2

Leading cause of cirrhosis

Answer 2

Chronic hepatitis B and C.
NAFLD
Alcoholic liver disease.

Question 3

Pathophysiology of cirrhosis

Answer 3

There’s an accumulation of collagen types I and III in the parenchyma and space of Disse.
Space of Disse loses fenestration thereby altering exchange between hepatocytes and plasma.
Increased pressure within the portal venous system as well as shunting blood away from the liver.
This leads to portal HTN, which underlines ascites and gastro-oesophageal varices.

Question 4

What is the Child-Pugh classification?

Answer 4

Class A- Well compensated
Class B- Partially compensated
Class C- Decompensated.

Question 5

Can cirrhosis be asymptomatic?

Answer 5

Almost 40% of people with cirrhosis are asymptomatic until the end stage of disease.

Question 6

Signs and symptoms of cirrhosis

Answer 6

Leukonychia 
Palmar erythema 
Spider angiomata 
Bruising 
Finger clubbing 
Dupuytren's contracture in ALD 
Finger clubbing 
Cyanosis 
Gynaecomastia 
Hepatomegaly 
Splenomegaly 
Loss of secondary sexual hair 
Testicular atrophy in men

Question 7

Diagnosis of cirrhosis

Answer 7

LFTs
GGT
PT 
Abdominal CT
MRI 
Biopsy (old)
Elastography (new)

Question 8

Management of cirrhosis

Answer 8

Treat underlying cause
Early detection is pivotal
Treatment of complications
Liver transplantation (decompensated disease)

Question 9

Causes of liver disease

Answer 9

Viral hepatitis 
NAFLD 
ALD 
Liver cancer 
Hepatic damage could be secondary to heart failure, disseminated cancer and extrahepatic infections. 
Epstein-barr virus 
Gallstones 
Pancreatic cancer 
Methotrexate 
Wilson's disease 
Obesity 
Primary biliary cholangitis 
Anti-epileptics 
Primary sclerosing cholangitis 
Diabetes mellitus 
Paracetamol overdose

Question 10

Right upper abdomen differential diagnoses

Answer 10

Structure above the diaphragm: Pleuritic pain, inferior MI

Structure below the diaphragm: Liver, gallbladder, pancreas, bowels, kidneys.

Question 11

Causes of cirrhosis

Answer 11

Common:
NAFLD, NASH
ALD
Viral hepatitis
Rare:
Haemochromatosis.
Primary biliary cirrhosis.
Biliary obstruction (may be due to biliary atresia/neonatal hepatitis, congenital biliary cysts or cystic fibrosis.
Autoimmune hepatitis.
Inherited metabolic disorders - eg, tyrosinaemia, Wilson’s disease, porphyria, alpha-1-antitrypsin deficiency, glycogen storage diseases.
Sarcoidosis or other granulomatous disease.
Primary sclerosing cholangitis.
Venous outflow obstruction in Budd-Chiari syndrome or veno-occlusive disease.
Drugs and toxins including methotrexate, amiodarone and isoniazid

Question 12

What is included in the Child-Pugh Critieria?

Answer 12

1. Albumin level
2. Bilirubin
3. INR
4. Ascites
5. Hepatic encephalopathy

Question 13

Complications of cirrhosis

Answer 13

Anaemia, thrombocytopenia and coagulopathy
Hepatocellular carcinoma
Gastro-oesophageal varices
Ascites
Spontaneous bacterial peritonitis (associated with ascites)

Question 14

What might precipitate decompensation in previously stable liver cirrhosis?

Answer 14

Infections.
Alcohol abuse
GI bleeding
Hypoglycaemia

Question 15

What is ascites?

Answer 15

Ascites is the abnormal accumulation of fluid in the peritoneal cavity.

Question 16

Causes of ascites

Answer 16

A common complication of diseases presenting with portal hypertension (e.g., liver cirrhosis, acute liver failure) and/or hypoalbuminemia (e.g., nephrotic syndrome).
Other conditions resulting in ascites are chronic heart failure, visceral inflammation (e.g., pancreatitis), and malignant tumours.

Question 17

Clinical features of ascites

Answer 17

Clinical features include progressive abdominal distension, shifting dullness, and a positive fluid wave test.
Ascites may be associated with abdominal pain in rare cases.
An adequate clinical assessment should be followed by imaging (e.g., ultrasound), which helps to identify even very small quantities of ascitic fluid in the peritoneal cavity.

Question 18

What should you do if the cause of ascites is unclear or spontaneous?

Answer 18

If the onset of ascites is spontaneous or the origin is unclear, an abdominal paracentesis and ascitic fluid assessment may be performed (i.e., to determine the appearance, composition).

Question 19

What is the serum ascites albumin gradient (SAAG)?

Answer 19

This is the amount of albumin in the ascitic fluid.

SAAG is used to differentiate between transudate and exudate causes of ascites.

Question 20

What does a SAAG of > 1.1 g/l indicate?

Answer 20

Transudate cause- Portal HTN.

Question 21

What does a SAAG of < 1.1 g/l indicate?

Answer 21

Exudate cause: 
Hypoalbuminaemia- nephrotic syndrome, severe malnutrition, protein-losing enteropathy
Pancreatitis
Infection-TB 
Malignancy

Question 22

Management of ascites

Answer 22

Diuretic therapy
Indications
Portal hypertensive ascites: usually responsive; may be treated in the same way as ascites caused by liver cirrhosis.
Non-portal hypertensive ascites (exudate): usually not effective; therefore it is essential to focus on treating the underlying disease!
Approach
Spironolactone
Additionally, or in the case of massive ascites: loop diuretics
Regular control of potassium and creatinine during diuretic therapy
Treatment of refractory ascites
Indication: inadequate response to diuretics, frequent recurrence, or when diuretic therapy is contraindicated
Procedures
Therapeutic large-volume paracentesis
Transjugular intrahepatic portosystemic shunt

Question 23

What is an osmotic laxative used for patients at risk of hepatic encephalopathy?

Answer 23

Lactulose - 30ml TDS Oral