Cirrhosis Flashcards
Definition
End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes.
Decompensation of cirrhosis
· Cirrhosis is considered DECOMPENSATED if it becomes complicated by any of: o Ascites o Jaundice o Encephalopathy o GI bleed
· Decompensation can be precipitated by infection, GI bleeding, constipation, high-protein meal, electrolyte imbalances, alcohol and drugs, tumour development or portal vein thrombosis
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 o a1-antitrypsin deficiency o Haemochromatosis o Wilson's disease o Galactosaemia o Cystic Fibrosis
· Vascular
o Budd-Chiari Syndrome
o Hepatic Venous Congestion
· Chronic Biliary Diseases
o PBC
o PSC
o Biliary atresia
· Unknown: 5-10%
· Non-Alcoholic Steatohepatitis (NASH)
o Associated with obesity, diabetes, total parenteral nutrition, short bowel syndromes, hyperlipidaemia and drugs (e.g. amiodarone, tamoxifen)
Presenting symptoms (early)
· Early non-specific symptoms: o Anorexia o Nausea o Fatigue o Weakness o Weight loss
Presenting symptoms (decreased liver synthetic function)
o Easy bruising
o Abnormal swelling
o Ankle oedema
Presenting symptoms (reduced detoxification function)
o Jaundice
o Personality change
o Altered sleep pattern
o Amenorrhoea
o Galactorrhoea
Presenting symptoms (portal hypertension)
o Abdominal swelling
o Haematemesis
o PR bleeding or melaena
3 symptoms to remember for portal hypertension:
Visible veins on abdomen
Splenomegaly
Ascites
Epidemiology
One of the top 10 causes of death worldwide
Signs on physical examination
These are all signs of chronic liver disease
· Asterixis · Bruises · Clubbing · Dupuytren's contracture · Palmar erythema · Jaundice · Gynaecomastia · Leukonychia · Parotid enlargement · Spider naevi · Scratch mark (from cholestatic pruritis) · Ascites · Enlarged liver (may be shrunken in the later stages) · Testicular atrophy · Caput medusae · Splenomegaly
Investigations (bloods)
o FBC: low platelets + Hb = because of hypersplenism as a result of portal hypertension
o LFTs - may be normal but often get:
· High AST, ALT, ALP, GGT and bilirubin
· Low albumin
o Clotting: prolonged PT
o Serum AFP (alpha-fetoprotein = tumour marker for liver cancer):
· Raised in chronic liver disease
· High levels may suggest hepatocellular carcinoma
Investigations (to determine cause)
o Viral serology
o a1-antitrypsin
o Caeruloplasmin
· This is a copper-carrying complex that is LOW in Wilson’s disease
o Iron studies: serum ferritin, iron, total iron binding capacity (TIBC) - check for haemochromatosis
o Anti-mitochondrial antibody (PBC)
o ANA, ASMA (autoimmune hepatitis)
Investigations (ascitic tap)
o MC&S - check for infection
o Biochemistry (protein, albumin, glucose, amylase)
o Cytology
o IMPORTANT: ascitic tap with neutrophils > 250/mm3 = spontaneous bacterial peritonitis (SBP)
Investigations (liver biopsy)
o Performed either:
· Percutaneously
· Transjugular - if clotting deranged or ascitic
o Histopathological features of cirrhosis:
· Periportal fibrosis
· Loss of normal liver architecture
· Nodular appearance
o Grade - indicates degree of inflammation
o Stage - degree of architectural distortion (from mild portal fibrosis –> cirrhosis)
Investigations (imaging)
· Imaging
o US, CT or MRI - to detect complications such as: · Ascites · HCC · Hepatic or portal vein thrombosis · Exclude biliary obstruction
o MRCP (if PSC suspected)
· Endoscopy
o To examine varices
Investigations (Child-Pugh grading)
· Child-Pugh Grading - score for estimating the prognosis in chronic liver disease/cirrhosis. It is based on 5 factors:
o Albumin o Bilirubin o PT o Ascites o Encephalopathy
· Cirrhosis can be divided into Classes using the Child-Push grading system:
o Class A: 5-6
o Class B: 7-9
o Class C: 10-15
