Cirrhosis Flashcards
What is cirrhosis?
Irreversible liver damage.
There is histological loss of normal architecture with bridging fibrosis and nodular regeneration.
There are many causes of liver cirrhosis, however the end result is always the same.
This means that treatment and complications will be the same regardless of aetiology.
Causes of cirrhosis.
Most often due to chronic alcohol abuse, HBV or HCV infection.
Can also be;
Genetics - haemochromatosis, alpha1-antitrypsin def., Wilson’s disease
Hepatic vein evet (Budd-Chiari)
Non-alcoholic steatohepatitis
Autoimmune - PBC, PSC
Drugs like amiodarone, methyldopa and methotrexate
Signs of cirrhosis.
Ascites
Splenomegaly
Leuconychia - due to hypoalbuminaemia
Terry’s nails - white proximally but distal 1/3 reddened by telangiectasias
Clubbing
Palmar erythema
Dupuytren’s contracture
Spider naevi
Xanthelasma
Gynaecomastia
Atrophic testes
Loss of body hair
Parotid enlargement
Hepatomegaly
Small liver in late disease
Blood investigations in cirrhosis.
LFTs
Albumin
PT/INR
WCC
Platelets
Ferritin
Iron
Serology for hepatitis
Immunoglobulins
Autoantibodies (ANA, AMA, SMA)
Alpha-feto protein
Ceruloplasmin if less than 40 yo
Other investigations of liver cirrhosis.
Liver ultrasound+duplex
MRI
Ascitic tap
Liver biopsy
When should you suspect cirrhosis?
In any patient with chronic liver disease who has thrombocytopenia or clinical stigmata of chronic liver disease.
Findings on liver ultrasound and duplex.
May show a small liver or hepatomegaly depending on how far gone the disease is.
Splenomegaly
Coarse texture of liver
Nodularity
Focal liver lesions
Hepatic vein thrombus
Reversed flow in the portal vein
Ascites
Findings on MRI.
Increased caudate lobe size
Smaller islands of regenerating nodules
Presence of the right posterior hepatic notch are more frequent in alcoholic cirrhosis than in virus-induced.
What is sometimes preferred instead of imaging?
Fibroscan.
It is quicker and more specific and can be performed in the clinic room.
Diagnostis of cirrhosis.
Clinical history
History of chronic liver disease
Findings on USS and fibroscan
Evidence of varices on endoscopy.
Liver biopsy is definitive but usually not needed because at this time it is unlikely that this will give you any clue as to the underlying pathology.
What should be screened for in cirrhosis?
Varices
Why is it important to screen for varices in cirrhosis?
So prophylaxis can be introduced in order to decrease the risk of bleeding
Complications of cirrhosis.
Can be divided into hepatic failure and portal hypertension.
Complications of cirrhosis in regards to hepatic failure.
Coagulopathy
Encephalopathy
Hypoalbuminaemia leading to oedema
Sepsis
Spontaneous bacterial peritonitis
Hypoglycaemia
Complications of cirrhosis in regards to portal hypertension.
Ascites
Splenomegaly
Portosystemic shunt including oesophageal varices, caput medusae and anorectal varices.
Cirrhosis (not related to portal HTN) can also lead to hepatocellular carcinoma.
When should an ascitic tap be done?
If there is suspicion of peritonitics.
>250/mm3 of neutrophils indicates SBP.
General management of cirrhosis.
Good nutrition
Alcohol abstinence
Avoid NSAIDs, sedatives and opiates
Colestyramine can help pruritus
Screening of hepatocellular carcinoma in cirrhosis.
Ultrasound +/- alpha-fetoprotein every 6 months.
Treatment of ascites in cirrhosis.
Fluid restriction ( < 1.5L/d)
Low salt diet
Spironolactone
Chart daily weight and aim for weight loss of half a kg or less a day.
Therapeutic paracentesis with concomitant albumin infusion may be required if the ascites is resistant.
Treatment of SBP in cirrhosis.
Must be considered in any patient with ascites who deteriorates suddenly.
The common organisms are E. coli, Klesbiella and streptococci.
Piperacillin with tazobactam 4.5g/8h for 5d should be given until sensitvities are known.
Give prophylaxis for high-risk patients e.g. ciprofloxacin 500mg PO daily.
Treatment of encephalopathy in cirrhosis.
Lactulose and rifaximin can be given as prophylaxis.
Prognsosis of cirrhosis.
5 yr survival is around 50%
Poor prognostic indicators include encephalopathy, hyponatremia and hypoalbuminaemia as well as increased INR.
What is the only definitive treatment for cirrhosis?
Liver transplantation.
Acute indications of liver transplant.
Acute liver failure meeting King’s College Criteria
Chronic indication of liver transplant.
Advanced cirrhosis of any cause
Hepatocellular cancer
What is the first line recommended investigation in assessing fibrosis in non-alcoholic fatty liver disease?
Enhanced Liver Fibrosis (ELF) blood test
It measures three markers;
HA
PIIINP
TIMP-1
Gives a scoring that indicates fibrosis of the liver.
What is fibroscan?
Checks the elasticity of the liver by sending high frequency sound waves into the liver.
It helps assess the degree of cirrhosis. This is called “transient elastography” and should be used to test for cirrhosis.
What patients should be scanned with fibroscan every 2 years?
NICE recommend retesting every 2 years in patients at risk of cirrhosis:
Hep C
Heavy alcohol drinkers (men drinking > 50 units or women drinking > 35 units per week)
Diagnosed alcoholic liver disease
Non alcoholic fatty liver disease and evidence of fibrosis on the ELF blood test
Chronic hepatitis B (although they suggest yearly for hep B)
What scoring systems are used in liver cirrhosis
Child-Pugh score
MELD score
Explain Child-Pugh score
Indicates severity of disease and prognosis
Explain MELD score
Suggested by NICE to be done every 6 months in patients with compensated liver cirrhosis.
It takes into account bilirubin, INR and sodium.
It tries to figure out whether the patient needs dialysis or not.
It gives a percentage of 3 month mortality and helps guide referral for liver transplant.
General management of liver cirrhosis
Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
Endoscopy every 3 years in patients without known varices
High protein, low sodium diet
MELD score every 6 months
Consideration of a liver transplant
Managing complications
Treatment of stable varices
Propranolol reduces portal hypertension by acting as a non-selective beta blocker
Elastic band ligation of varices
Injection of sclerosant (less effective than band ligation)
TIPSS
Management of bleeding oesophageal varices
Resuscitation
Terlipressin cause vasoconstriction and slow bleeding in varices
Correct any coagulopathy with vitamin K and fresh frozen plasma (which is full of clotting factors)
Giving prophylactic broad spectrum antibiotics has been shown to reduce mortality
Consider intubation and intensive care as they can bleed very quickly and become life threateningly unwell
Urgent endoscopy
Injection of sclerosant into the varices can be used to cause “inflammatory obliteration” of the vessel
Elastic band ligation of varices
Sengstaken-Blakemore Tube is an inflatable tube inserted into the oesophagus to tamponade the bleeding varices. This is used when endoscopy fails.
What is an orthotopic liver transplant
When an entire liver is transplanted from a deceased patient to a recipient it is known as an orthotopic transplant.
Factors suggesting unsuitability for liver transplantation.
Significant co-morbidities (e.g. severe kidney or heart disease)
Excessive weight loss and malnutrition (suggesting they won’t tolerate surgery)
Active hepatitis B, hepatitis C or other infection
End-stage HIV
Active alcohol use (generally 6 months of abstinence is required)
Post-transplantation care.
Patients will require lifelong immunosuppression (e.g. steroids, azathioprine and tacrolimus)
Avoid alcohol and smoking
Treating opportunistic infections
Monitoring for disease recurrence (i.e. of hepatitis or primary biliary cirrhosis)
Monitoring for cancer as there is a significantly higher risk in immunosuppressed patients
Monitoring for evidence of liver transplant rejection.
Abnormal LFTs
Fatigue
Fever
Jaundice
