Cirrhosis Flashcards
what is definately raised in liver cirrhosis?
Albumin and PT will defo be abnormal
define cirrhosis?
End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes – this is IRREVERSIBLEliver damage
describe the histology of cirrhosis?
bridging fibrosis + nodular regeneration
when is cirrhosis considered decompensated?
becomes complicated by any of:
J BAE
Jaundice
GI bleed (bleeding varices)
Ascites
Encephalopathy
what can precipitate decompensation?
GI bleeding, constipation, high-protein meal, electrolyte imbalances, alcohol and drugs, tumour development or portal vein thrombosis
summarise the epidemiology of cirrhosis?
Among the top 10 leading causes of deaths worldwide
outline the aetiology/risk factors for liver cirrhosis?
Chronic alcohol misuse (most common in the UK)
Chronic viral hepatitis (hep B/C - most common worldwide)
Autoimmune hepatitis
Drugs (e.g. methotrexate, methyldopa, amiodarone and other hepatotoxic drugs)
Inherited
vascular
chronic biliary diseases- PBC , PSC, Biliary atresia
NASH
what drugs cause liver cirrhosis?
methortrexate
methyldopa
amiodarone
other hepatotoxic drugs
what are the inherited causes of liver cirrhosis?
alpha1-antitrypsin deficiency
Haemochromatosis
Wilson’s disease – autosomal recessive condition characterised by excess copper
Galactosaemia
Cystic Fibrosis
what are the vascular causes of liver cirrhosis?
Budd-Chiari Syndrome – occlusion of hepatic veins that drain liver
Hepatic Venous Congestion
what are the early non-specific symptoms of liver cirrhosis?
Anorexia
Nausea
Fatigue
Weakness
Weight loss
what are the symptoms of liver cirrhosis which are due to decreased synthetic liver function?
Easy bruising
Abnormal swelling
Ankle oedema – cirrhosis slows the normal blood flow through the liver, thus increasing pressure in the vein that brings blood from the intestines and spleen to the liver
Leuconychia – due to hypoalbuminaemia
what are the symptoms of liver cirrhosis which are due to reduced detoxifcation?
Jaundice
Personality change
Altered sleep pattern
Amenorrhoea
Galactorrhoea
what are the symptoms of liver cirrhosis due to portal hypertension?
Abdominal swelling
Haematemesis
PR bleeding or melaena
what are the signs of chronic liver disease?
Asterixis/ascites
Bruises
Clubbing and caput medusae
Dupuytren’s contracture
In the early stages management is largely conservative but if function is affected then surgery is indicated. Surgery involves excising the thickened aponeurosis and would be followed by a period of splinting and physiotherapy to restore hand function. Re-thickening can occur so surgery may need to be repeated.
Palmar Erythema
Fat spleen – splenomegaly and fetor hepaticus
Gynaecomastia
Hair loss – bodily hair and hepatomegaly (may be shrunken in the later stages)
Itching due to bile products being deposited in the skin (cholestatic pruritis)
Jaundice
Leukonychia
Mini testicles – testicular atrophy/ muscle wasting
Spider naevi – consist of a central arteriole from which numerous vessels radiate, occur most commonly in skin drained by the superior vena cava, up to 5 are normal
Other causes: contraceptive steroids, pregnancy
Parotid enlargement
Terry’s nails – white proximally but distal 1/3 reddened
Xanthelasma
describe the bloods in liver cirrhosis?
FBC: low platelets + Hb = because of hypersplenism as a result of portal hypertension
LFTs - may be normal but often get:
- High AST, ALT, ALP, GGT and bilirubin
- Low albumin
Seum sodium – reduced and worsens as cirrhosis progressed
Clotting: prolonged PT
Serum AFP (alpha-fetoprotein = tumour marker for liver cancer):
- Raised in chronic liver disease
- High levels may suggest hepatocellular carcinoma
what are the investigations to determine the cause of liver cirrhosis?
Viral serology
a1-antitrypsin
Caeruloplasmin- This is a copper-carrying complex that is LOW in Wilson’s disease
Iron studies: serum ferritin, iron, total iron binding capacity (TIBC) - check for haemochromatosis
Anti-mitochondrial antibody (PBC)
ANA, ASMA (autoimmune hepatitis)
what do we look for in an ascitic tap?
Microscopy, culture and sensitivity - check for infection
Biochemistry (protein, albumin, glucose, amylase)
Cytology
IMPORTANT: ascitic tap with neutrophils > 250/mm3 = spontaneous bacterial peritonitis (SBP)
what does an ascitic tap with neutrophils more than 250 indicate?
spontaneous bacterial peritonitis ( SBP)
What test confirms the clinical diagnosis?
liver biopsy
what are the 2 ways a liver biopsy can be performed?
Percutaneously
Transjugular - if clotting deranged or ascitic
what are the histopsthological features of cirrhosis?
Periportal fibrosis
Loss of normal liver architecture
Nodular appearance
- Grade - indicates degree of inflammation
- Stage - degree of architectural distortion (from mild portal fibrosis –> cirrhosis)
what are the investigations for liver cirrhosis?
bloods
investigations to find cause
ascitic tap
liver biopsy
imaging- US, CT, MRI
Endoscopy
what imaging is done and what are they used to detect?
US, CT or MRI - to detect complications such as:
- Ascites
- HCC
- Hepatic or portal vein thrombosis
- Exclude biliary obstruction
MRCP (if PSC suspected)
what is endoscopy used for?
examine varices
what is the scoring system to investigate the prognosis of chronic liver disease/cirrhosis and what are the 5 factors it is based on?
Child-Pugh Grading
- Albumin
- Bilirubin
- PT
- Ascites
- Encephalopathy
what are the 3 classes that cirrhosis can be divided into using the child pugh grading system?
Class A: 5-6
Class B: 7-9
Class C: 10-15
outline the management plan for liver cirrhosis?
Treat the CAUSE if possible
Avoid alcohol, sedatives, opiates, NSAIDs and drugs that affect the liver
Imms against Hep A and B for susceptible patients
Nutrition is important
Enteral supplements should be given
NG feeding may be indicated
Treating Complications- encephalopathy, ascites, spontaneous bacterial peritonitis
Surgical
describe the management of encephalopathy?
Treat infections
Exclude GI bleed
Use lactulose and phosphate enemas
Avoid sedation
how does lactulose treat encephalopathy?
lactulose reduces the absorption of ammonia from the gut. This helps prevent encephalopathy caused by ammonia reaching the brain
describe the treatment of ascites?
Diuretics (spironolactone with/without furosemide)
Dietary sodium restriction
Therapeutic paracentesis (with human albumin replacement)
Monitor weight
Fluid restrict if plasma sodium < 120 mmol/L
Avoid alcohol and NSAIDs
describe the treatment of SBP?
Antibiotics (e.g. cefuroxime and metronidazole)
Prophylaxis against recurrent SBP with ciprofloxacin
Describe the surgical management of liver cirrhosis?
Consider TIPS (transjugular intrahepatic portosystemic shunt) - this helps reduce portal hypertension
However, it may precipitate encephalopathy because it is providing a route for blood from the GI tract to bypass the liver
Liver transplantation is the only curative method
what are the possible complications of liver cirrhosis/
Portal hypertension with ascites
Hepatic encephalopathy: This condition is precipitated by the liver’s inability to convert toxic ammonia into urea which can freely cross the BBB causing CNS symptoms.
Variceal haemorrhage
SBP
HCC
Renal failure (hepatorenal syndrome)
Pulmonary hypertension (hepatopulmonary syndrome)
summarise the prognosis of patients with liver cirrhosis?
Depends on aetiology and complications
Generally poor prognosis
- Overall 5 year survival = 50%
- If ascites, 2 year survival = 50%
Poor prognostic indicators: encephalopathy, serum Na+ <110 mmol/L, serum albumin <25g/L, high INR
