Cirrhosis Flashcards
Define Cirrhosis?
End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes
When is Cirrhosis considered Decompensated?
If it becomes complicated by any of:
- Ascites
- Jaundice
- Encephalopathy
- GI bleed
What can Decompensation of Cirrhosis be precipitated by?
Infection GI bleeding Constipation High-protein meal Electrolyte imbalances Alcohol and drugs Tumour development or portal vein thrombosis
What is the general aetiology of Cirrhosis?
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)
What are some of the inherited causes of Cirrhosis?
a1-antytypsin deficiency Haemochromatosis Wilson's Disease Galactosaemia Cystic Fibrosis
What are the vascular causes of Cirrhosis?
Budd-Chiari Syndrome
Hepatic Venous Congestion
What are some of the Chronic Biliary Disease that can cause Cirrhosis?
PBC
PSC
Biliary atresia
What percentage of cirrhosis cases is there an unknown cause?
5-10%
What is the other main cause of Cirrhosis?
Non-Alcoholic Steatohepatitis (NASH)
What is NASH associated with?
Obesity Diabetes Total parenteral nutrition Short bowel syndromes Hyperlipidaemia and drugs (e.g. amiodarone and tamoxifen)
What are the Early non-specific symptoms of Cirrhosis?
Anorexia Nausea Fatigue Weakness Weight Loss
What symptoms that are due to decreased liver synthetic function are present in Cirrhosis?
Easy Bruising
Abnormal swelling
Ankle Oedema
What symptoms due to reduced detoxification function are present in Cirrhosis?
Jaundice Personality change Altered sleep pattern Amenorrhoea Galactorrhoea
What symptoms due to portal hypertension are present in Cirrhosis?
Abdominal Swelling
Haematemesis
PR bleeding or melaena
What is the epidemiology of Cirrhosis?
One of the top 10 causes of death worldwide
What are the signs of Cirrhosis on physical examination?
Signs of Chronic Liver Disease
What are the Signs of 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
What investigations would you do for Cirrhosis?
Bloods Investigations to determine cause Ascitic Tap Liver Biopsy Imaging Endoscopy Child-Pugh Grading
What Bloods would you do specifically for Cirrhosis?
FBC
LFTs
Clotting
Serum AFP (alpha-fetoprotein)
What would you look for on a FBC for Cirrhosis?
Low platelets + Hb = because of hypersplenism as a result of portal hypertension
What would you look for on LFTs for Cirrhosis?
May be normal but often get:
- High AST, ALT, ALP, GGT and bilirubin
- Low albumin
What would you look for specifically on clotting tests for Cirrhosis?
Prolonged PT
What is alpha-fetoprotein?
Tumour marker for liver cancer
Why do we do serum AFP tests for Cirrhosis?
Raised in chronic liver disease
High levels may suggest hepatocellular carcinoma
What investigations to determine cause do we do for Cirrhosis?
Viral Serology a1-antitrypsin Caeruloplasmin Iron Studies Anti-mitochondrial antibody (PBC) ANA, ASMA (autoimmune hepatitis)
What is Caeruloplasmin?
Copper-carrying complex that is LOW in Wilson’s Disease
What specifically would you look at related to iron to determine the cause of Cirrhosis?
Serum ferritin, iron
Total Iron binding capacity (TIBC)
Why do we do iron related tests for Cirrhosis?
Check for haemochromatosis
What do we look at on an Ascitic Tap for Cirrhosis?
MC&S - check for infection
Biochemistry (protein, albumin, glucose, amylase)
Cytology
What’s important to remember with the Ascitic Tap?
An ascitic tap with neutrophils > 250/mm^3 = spontaneous bacterial peritonitis (SBP)
How is a Liver Biopsy performed for Cirrhosis?
Percutaneously
Transjugalar - if clotting deranged or ascitic
What are the histopathological features of Cirrhosis seen on a Liver biopsy?
Periportal Fibrosis
Loss of normal liver architecture
Nodular appearance
What does ‘grade’ refer to with regards to Cirrhosis?
Indicates degree of inflammation
What does ‘stage’ refer to with regards to Cirrhosis?
Degree of architectural distortion (from mild portal fibrosis to cirrhosis)
What imaging do we do for Cirrhosis?
US, CT or MRI - to detect complications such as:
- Ascites
- HCC
- Hepatic or portal vein thrombosis
- Exclude biliary obstruction
MRCP (is PSC suspected)
When do we do an Endoscopy for Cirrhosis?
To examine varices
What is Child-Pugh Grading?
Score for estimating the prognosis in chronic liver disease/cirrhosis
What factors is Child-Pugh Grading based on?
Albumin Bilirubin PT Ascites Encephalpathy
What are the classes that Cirrhosis can be divided into based on the Child-Pugh Grading System?
Class A: 5-6
Class B: 7-9
Class C: 10-15
What is the management plan for Cirrhosis?
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
How do we treat Encephalopathy if it becomes a complication of Cirrhosis?
Treat Infections
Exclude GI bleed
Use lactulose and phosphate enemas
Avoid sedation
How do Lactulose and phosphate enemas help with encephalopathy?
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
How do you treat Ascites if it becomes a complication of Cirrhosis?
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
How do you treat Spontaneous Bacterial Peritonitis if it becomes a complication of Cirrhosis?
Antibiotics (e.g. cefuroxime and metronidazole)
Prophylaxis against recurrent SBP with ciprofloxacin
What is the surgical management plan for Cirrhosis?
Consider TIPS - Transjugalar intrahepatic portosystemic shunt)
Liver Transplantation is the only curative method
Why would we do TIPS for Cirrhosis?
It helps to reduce portal hypertension
What is the cons of TIPS for Cirrhosis?
It may precipitate encephalopathy because it is providing a route for blood from the GI tract to bypass the liver
What are the possible complications of Cirrhosis?
Portal Hypertension with ascites Hepatic encephalopathy Variceal Haemorrhage SBP HCC Renal Failure (hepatorenal syndrome) Pulmonary hypertension (hepatopulmonary syndrome)
What is the prognosis for patients with Cirrhosis?
Depends on aetiology and complications
Generally poor prognosis
-Overall 5 year survival = 50%
-If ascites, 2 year survival = 50%
