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Gastrointestinal > Cirrhosis > Flashcards

Cirrhosis Flashcards

1
Q

Define Cirrhosis?

A

End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes

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2
Q

When is Cirrhosis considered Decompensated?

A

If it becomes complicated by any of:

  • Ascites
  • Jaundice
  • Encephalopathy
  • GI bleed
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3
Q

What can Decompensation of Cirrhosis be precipitated by?

A 
Infection
GI bleeding
Constipation
High-protein meal
Electrolyte imbalances
Alcohol and drugs 
Tumour development or portal vein thrombosis
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4
Q

What is the general aetiology of Cirrhosis?

A

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)

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5
Q

What are some of the inherited causes of Cirrhosis?

A 
a1-antytypsin deficiency
Haemochromatosis 
Wilson's Disease
Galactosaemia 
Cystic Fibrosis
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6
Q

What are the vascular causes of Cirrhosis?

A

Budd-Chiari Syndrome

Hepatic Venous Congestion

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7
Q

What are some of the Chronic Biliary Disease that can cause Cirrhosis?

A

PBC
PSC
Biliary atresia

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8
Q

What percentage of cirrhosis cases is there an unknown cause?

A

5-10%

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9
Q

What is the other main cause of Cirrhosis?

A

Non-Alcoholic Steatohepatitis (NASH)

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10
Q

What is NASH associated with?

A 
Obesity 
Diabetes 
Total parenteral nutrition
Short bowel syndromes
Hyperlipidaemia and drugs (e.g. amiodarone and tamoxifen)
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11
Q

What are the Early non-specific symptoms of Cirrhosis?

A 
Anorexia
Nausea
Fatigue 
Weakness 
Weight Loss
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12
Q

What symptoms that are due to decreased liver synthetic function are present in Cirrhosis?

A

Easy Bruising
Abnormal swelling
Ankle Oedema

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13
Q

What symptoms due to reduced detoxification function are present in Cirrhosis?

A 
Jaundice 
Personality change 
Altered sleep pattern
Amenorrhoea 
Galactorrhoea
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14
Q

What symptoms due to portal hypertension are present in Cirrhosis?

A

Abdominal Swelling
Haematemesis
PR bleeding or melaena

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15
Q

What is the epidemiology of Cirrhosis?

A

One of the top 10 causes of death worldwide

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16
Q

What are the signs of Cirrhosis on physical examination?

A

Signs of Chronic Liver Disease

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17
Q

What are the Signs of Liver Disease?

A 
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
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18
Q

What investigations would you do for Cirrhosis?

A 
Bloods 
Investigations to determine cause 
Ascitic Tap
Liver Biopsy 
Imaging 
Endoscopy
Child-Pugh Grading
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19
Q

What Bloods would you do specifically for Cirrhosis?

A

FBC
LFTs
Clotting
Serum AFP (alpha-fetoprotein)

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20
Q

What would you look for on a FBC for Cirrhosis?

A

Low platelets + Hb = because of hypersplenism as a result of portal hypertension

21
Q

What would you look for on LFTs for Cirrhosis?

A

May be normal but often get:

  • High AST, ALT, ALP, GGT and bilirubin
  • Low albumin
22
Q

What would you look for specifically on clotting tests for Cirrhosis?

A

Prolonged PT

23
Q

What is alpha-fetoprotein?

A

Tumour marker for liver cancer

24
Q

Why do we do serum AFP tests for Cirrhosis?

A

Raised in chronic liver disease

High levels may suggest hepatocellular carcinoma

25
Q

What investigations to determine cause do we do for Cirrhosis?

A 
Viral Serology 
a1-antitrypsin
Caeruloplasmin
Iron Studies 
Anti-mitochondrial antibody (PBC)
ANA, ASMA (autoimmune hepatitis)
26
Q

What is Caeruloplasmin?

A

Copper-carrying complex that is LOW in Wilson’s Disease

27
Q

What specifically would you look at related to iron to determine the cause of Cirrhosis?

A

Serum ferritin, iron

Total Iron binding capacity (TIBC)

28
Q

Why do we do iron related tests for Cirrhosis?

A

Check for haemochromatosis

29
Q

What do we look at on an Ascitic Tap for Cirrhosis?

A

MC&S - check for infection
Biochemistry (protein, albumin, glucose, amylase)
Cytology

30
Q

What’s important to remember with the Ascitic Tap?

A

An ascitic tap with neutrophils > 250/mm^3 = spontaneous bacterial peritonitis (SBP)

31
Q

How is a Liver Biopsy performed for Cirrhosis?

A

Percutaneously

Transjugalar - if clotting deranged or ascitic

32
Q

What are the histopathological features of Cirrhosis seen on a Liver biopsy?

A

Periportal Fibrosis
Loss of normal liver architecture
Nodular appearance

33
Q

What does ‘grade’ refer to with regards to Cirrhosis?

A

Indicates degree of inflammation

34
Q

What does ‘stage’ refer to with regards to Cirrhosis?

A

Degree of architectural distortion (from mild portal fibrosis to cirrhosis)

35
Q

What imaging do we do for Cirrhosis?

A

US, CT or MRI - to detect complications such as:

  • Ascites
  • HCC
  • Hepatic or portal vein thrombosis
  • Exclude biliary obstruction

MRCP (is PSC suspected)

36
Q

When do we do an Endoscopy for Cirrhosis?

A

To examine varices

37
Q

What is Child-Pugh Grading?

A

Score for estimating the prognosis in chronic liver disease/cirrhosis

38
Q

What factors is Child-Pugh Grading based on?

A 
Albumin
Bilirubin
PT 
Ascites 
Encephalpathy
39
Q

What are the classes that Cirrhosis can be divided into based on the Child-Pugh Grading System?

A

Class A: 5-6
Class B: 7-9
Class C: 10-15

40
Q

What is the management plan for Cirrhosis?

A 
Treat the cause if possible 
Avoid alcohol, sedatives, opiates, NSAIDs and drugs that affect the liver
Nutrition is important 
Enteral supplements should be given
NG feeding may be indicated
Treat Complications
41
Q

How do we treat Encephalopathy if it becomes a complication of Cirrhosis?

A

Treat Infections
Exclude GI bleed
Use lactulose and phosphate enemas
Avoid sedation

42
Q

How do Lactulose and phosphate enemas help with encephalopathy?

A

Normally, the liver breaks down ammonia that is absorbed in the GI tract, however, in Cirrhosis the ammonia can go through the liver without being broken down and exert toxic effects on the brain
Lactulose reduces the absorption of ammonia from the gut
This helps prevent encephalopathy caused by ammonia reaching the brain

43
Q

How do you treat Ascites if it becomes a complication of Cirrhosis?

A

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

44
Q

How do you treat Spontaneous Bacterial Peritonitis if it becomes a complication of Cirrhosis?

A

Antibiotics (e.g. cefuroxime and metronidazole)

Prophylaxis against recurrent SBP with ciprofloxacin

45
Q

What is the surgical management plan for Cirrhosis?

A

Consider TIPS - Transjugalar intrahepatic portosystemic shunt)
Liver Transplantation is the only curative method

46
Q

Why would we do TIPS for Cirrhosis?

A

It helps to reduce portal hypertension

47
Q

What is the cons of TIPS for Cirrhosis?

A

It may precipitate encephalopathy because it is providing a route for blood from the GI tract to bypass the liver

48
Q

What are the possible complications of Cirrhosis?

A 
Portal Hypertension with ascites 
Hepatic encephalopathy
Variceal Haemorrhage 
SBP
HCC
Renal Failure (hepatorenal syndrome)
Pulmonary hypertension (hepatopulmonary syndrome)
49
Q

What is the prognosis for patients with Cirrhosis?

A

Depends on aetiology and complications
Generally poor prognosis
-Overall 5 year survival = 50%
-If ascites, 2 year survival = 50%

Gastrointestinal (61 decks)

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