Cirrhosis

Question 1

What is cirrhosis?

Answer 1

Results from the necrosis of liver cells followed by fibrosis and nodule formation
Liver architecture is abnormal interferes with liver blood flow and function

Question 2

What are the common causes of cirrhosis?

Answer 2

Alcohol
Hep B (+- hep D)
Hep C

Question 3

What are the other causes of cirrhosis?

Answer 3

Biliary cirrhosis 
Autoimmune hepatitis
Hereditary haemochromatosis
Hepatic venous congestion
Budd-Chiari syndrome 
Wilson's disease
Drugs (methotrexate)
A1-antitrypsin deficiency
Cystic fibrosis

Question 4

What are the two types of cirrhosis seems under a microscope?

Answer 4

Micronodular- regeneration nodules are <3mm and liver is involved uniformly, alcohol damage or biliary tract disease
Macronodular- nodules are of variable size and normal acini may be seen within the larger nodules, previous hep B

Question 5

How can the type of cirrhosis be determined?

Answer 5

Viral markers
Serum autoantibodies 
Serum immunoglobulins 
Iron indices and ferritin
Copper, caeruloplasmin 
A1- antitrypsin

Question 6

What is the management for cirrhosis?

Answer 6

6-monthly ultrasound and a-fetoprotein

Those with compensated should avoid salt, aspirin, NSAIDs, alcohol

Question 7

What are the complications and effects of cirrhosis?

Answer 7

Portal hypertension and gastrointestinal haemorrhage
Ascites
Portosystemic encephalopathy
Renal failure
Hepatocellular carcinoma 
Bacteraemias, infections
Malnutrition

Question 8

How is portal hypertension classified?

Answer 8

Prehepatic- blockage of portal vein before liver
Intrahepatic- distortion of liver architecture (presinusoidal-schistosomiasis) (post sinusoidal- cirrhosis)
Posthepatic- venous blockage outside the liver (rare)

Question 9

What are the causes of portal hypertension?

Answer 9

Prehepatic- portal vein thrombosis
Intrahepatic- cirrhosis, hepatitis (alcoholic), schistosomiasis, congenital hepatic fibrosis, myelosclerosis
Posthepatic- Budd-chiari syndrome, vino-occlusive disease, right heart failure, constrictive pericarditis

Question 10

What are the clinical features of portal hypertension?

Answer 10

Often asymptomatic with splenomegaly
haematemesis or melaena from rupture of gastro-oesophageal varies or portal hypertensive gastropathy
Ascites
Encephalopathy

Question 11

What are the poor prognostic indicators in cirrhosis (blood test)?

Answer 11

Low albumin <28
Low serum sodium <125
PT > 6 of normal value
Raised creatine >160

Question 12

What are the poor prognostic indicators in cirrhosis (clinical)?

Answer 12

Persistent jaundice
Failure of response to therapy
Ascites
Haemorrhage from varices
Neuropsychiatric complications
Small liver
Persistent hypotension 
Alcoholic- keeps drinking

Question 13

What is ascites?

Answer 13

Presence of fluid within the peritoneal cavity, common complication of cirrhosis
Sodium and water retention occur (peripheral arterial vasodilation)
Portal hypertension (exerts local hydrostatic pressure
Low serum albumin (reduction in plasma oncotic pressure)

Question 14

What are the clinical features of ascites?

Answer 14

Abdominal swelling
Respiratory distress
Difficulty in eating
Peripheral oedema
Pleural effusion (right side)

Question 15

What is spontaneous bacterial peritonitis? (SBP)

Answer 15

Occurs in 8% of cirrhotics with ascites
Infecting organisms gain access to the peritoneum by haemotogenous spread
E. coli, klebsiella, enterococci
Raised neutrophil count (start treatment immediately)
25% mortality rate, 75% reoccurrence in a year
Indication for liver transplantation

Question 16

What is primary biliary cirrhosis?

Answer 16

Chronic disorder in which there is progressive destruction of bile ducts , eventually leading to cirrhosis
Asymptomatic- hepatomegaly, raised ALP or autoantibodies
Pruritus, jaundice, fatigue
Xanthelasma

Question 17

What are the investigations for primary biliary cirrhosis?

Answer 17

Mitochondrial antibodies
High ALP
High serum cholesterol 
High serum IgM
Ultrasound (alteration in liver architecture)
Liver biopsy

Question 18

What is secondary biliary cirrhosis?

Answer 18

Cirrhosis that results from prolonged large duct biliary obstruction
Bile duct strictures, gallstones, sclerosing cholangitis

Question 19

What is hereditary haemochromatosis?

Answer 19

Excess iron deposition in organs leading to fibrosis and organ failure
Autosomal recessive
Iron high in liver and pancreas
Most present in fifth decade
Triad- bronze skin pigmentation, hepatomegaly and diabetes
Hypogonadism secondary to pituitary dysfunction
Heart failure, arrhythmia

Question 20

What is Wilson’s disease?

Answer 20

Copper is incorporated into caeruloplasmin and secreted into the blood (usually secreted in bile)
Copper depositions in liver, basal ganglia of brain, cornea
Autosomal recessive
Children- hepatic problems Adults- neurological
Tremor, dysarthria, eventually dementia

Question 21

What are the investigations for Wilson’s disease?

Answer 21

Serum copper and caeruloplasmin (normally reduced)
High urinary copper
Liver biopsy (copper)
Hameolysis and anaemia

Question 22

What are the most common causes of exudative ascites?

Answer 22

Infection or malignancy