Cirrhosis Flashcards
Define cirrhosis.
End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes.
Decompensated= when there are complications such as ascites, jaundice, encephalopathy, or GI bleeding.
What is the aetiology of cirrhosis?
- Chornic alcohol misuse - most common UK cause
- Chronic viral hepatitis - hepatitis B and C are the most common causes of cirrhosis worldwide
- Autoimmune hepatitis
- Drugs - methotrexate, hepatotoxic drugs,
- Inherited - alpha1-antitrypsin, haemochromatosis, Wilson’s diseae, galactosaemia, cystic fibrosis
- Vascular - Budd-chiari syndrome, hepatic venous congestion
- Chronic biliary diseases - PBC, PSC, biliary atresia
- Cryptogenic - 5-10%
- NASH - increases risk; NASH is associated with obesity, diabetes, TPN, short bowel syndrome, hyperlipidaemia, drugs e.g. amiodarone and tamoxifen.
How common is cirrhosis?
One of the top 10 leading causes of death worldwide
Most common UK cause of cirrhosis = ETOH misuse
Most common worldwide causes = Hep B/C
What is the typical presentation of cirrhosis?
Early non-specific symptoms = anorexia, nausea, fatigue, weakness, weight loss
Symptoms caused by low liver synthetic function = easy bruising, abdo swelling, ankle oedema
Reduced detoxification function = jaundice, personality change, altered sleep pattern, amenorrhoea
Portal hypertension = abdominal swelling, haematemesis, PR bleeding, melaena
What are the signs of cirrhosis on examination?
Stigmata of chronic liver disease:
- Asterixis (‘liver flap’)
- Bruises
- Clubbing
- Dupuytren’s contracture
- Erythema (palmar)
Other:
Jaundice, gyaecomastia, leukonychia, parotid enlargementm spider naevi, scratch marks, ascites, (‘shifting dullness’, fluid thrill)
Enlarged liver (shrunken and small in later stages), testicular atrophy, caput medusae, splenomegaly (=portal hypertension)
What investigations should you do for cirrhosis?
Bloods:
- FBC - low Hb, low plt from hypersplenism
- LFTs - normal or high transaminases, alkphos, GGT, bilirubin and low albumin
- Clotting - prolonged PT (less clotting factor synthesis )
- Serum AFP - high in chronic liver disease, high levels may suggest hepatocellular carcinoma
Other:
- Viral serology - to determine cause e.g. HBsAg, HBsAb, HCV ab
- Alpha1 antitrypsin
- Caeruloplasmin (Wilson’s disease)
- Iron studies - serum ferritin, iron, total iron binding capaciy (haemachromatosis)
- Antimitochondrial antibody (PBC), ANA, SMA (autoimmune hepatitis)
Imaging :
US, CT or MRI abdo and liver - to visualise strctural lesions, ascites, carcinoma, hepatic/portal vein thrombosis, exclude biliary obstruction
ERCP/MRCP - to assess varices, portal hypertensive gastropathy
Invasive:
Ascitic tap - MC&S, biochemistry and cytology. If neutrophils >250/mm3 then SBP (spontaneous bacterial peritonitis)
Liver biopsy - percutaenous/transjugular if deranged clotting/ascites. Histopathology –> periportal fibrosis, loss of normal liver architecture and nodular appearance. Grade refers to assessment of degree of inflammation, whereas stage refers to degree of architectural distortion, ranging from mild portal fibrosis to cirrhosis.
What grading system is used for cirrhosis?
Child-Pugh grading - system for assessing the prognosis — including the required strength of treatment and necessity of liver transplant — of chronic liver disease, primarily cirrhosis
How is spontaneous bacterial peritonitis diagnosed?
Ascitic tap, MC&S, biochemistry (protein, glucose, albumin, amylase) and cytology.
If neutrophils >250/mm3 = spontaneous bacterial peritonitis
How do you manage cirrhosis?
Treat cause, avoid alcohol, sedative, opiates, NSAIDs and drugs that affect the liver.
Dietician support and enteral supplements - NG feeding may be indicated
Treating complications:
- Ascites
- Encephalopathy
- SBP
- Surgical
How do you manage encephalopathy ?
- Treat infection
- Exclude GI bleed
- Lactulose and phosphate enemas and avoid sedation
How do you manage ascites?
- Diuretics - spironolactone +/- furosemide
- Dietary sodium restriction - 88meq or 2g/day
- Therapeutic paracentesis - with human albumin replacement IV
- Monitor daily weight
- Fluid restriction in patients with plasma sodium <120mmol/L
- Avoid alcohol and NSAIDs
How do you manage spontaneous bacterial peritonitis (SBP)?
Antibiotic treatment (e.g. cefuroxime and metronidazole)
Prophylaxis against recurrent SBP with ciprofloxacin
What is the surgical management of cirrhosis?
- Insertion of TIPS to relieve portal hypertension (if recurrent variceal bleeds or diuretic-resistant ascites) although may percipitate encephalopathy
- Liver transplantation is the only curative option
What are the complications of cirrhosis?
- Portal hypertension with ascites
- Encephalopathy
- Variceal haemorrhage
- Hepatocellular carcinoma
- Renal failure (hepatorenal syndrome)
- Pulmonary hypertension (hepatopulmonary syndrome)
What is the prognosis with cirrhosis?
- Depends on aetiology and complications
- Generally poor - overall 5 yar survival is 50%
- In presence of ascites, 2year survival is 50%
