Cirrhosis Flashcards
Define Cirrhosis:
End-stage chronic liver damage with replacement of the normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes
What makes Cirrhosis decompensated?
If any of the following are present:
Ascites
Jaundice
Encephalopathy
GI bleed
This can be precipited by many many things
What are the common aetiologies of Cirrhosis?
Chronic alcohol misuse (most common in UK)
Chronic Viral hepatitis (B/C most common)
Autoimmune Hepatitis
Non-alcoholic steatohepatitis (NASH)
Hepatotoxic drugs (e.g. methotrexate)
Inherited pathologies
Vascular Pathologies
Chronic Biliary diseases (PBC, PSC, Biliary atresia)
What are the possible inherited disorders that cause Cirrhosis?
(5)
α1-antitrypsin deficiency
Haemochromatosis
Wilson’s
Galactosaemia
Cystic Fibrosis
Name a vascular condition that can cause Cirrhosis:
Budd-Chiari syndrome (occlusion of hepatic veins often due to thrombosis)
What are the common presenting symptoms of Cirrhosis?
Break them down into 4 sections..
Early non-specific: Anorexia, Nausea, Fatigue, Weakness, Weight loss
Decreased synthetic function: easy bruising, abnormal swelling, ankle oedema
Reduced detoxification function: Jaundice, personality change, altered sleep, Amenorrhoea, Galactorrhoea
Portal Hypertension: Abdo swelling, Haematemesis, PR bleeding, melaena
Name as many stigmata of Chronic Liver Disease as you can:
General: Jaundice, Ascites, Bruising
Hands: Clubbing, Leukonichia, Dupuytren’s Contracture, Palmar Erythema, Asterixis
Face: Parotid enlargement, Scleral icterus, Fetor hepaticus
Chest: Spider naevi, Gynaecomastia, scratch marks (cholestatic pruritis)
Abdo: Hepatomegaly, Splenomegaly, Caput Medusae, Testicular atrophy
What blood results might you expect with Cirrhosis?
FBC: Low PLT + Hb - due to hypersplenism as a result of portal htn
LFTs: derranged, everything high, albumin may be low
Clotting: Prolonged PT
Serum Alpha-fetoprotein (tumour marker for liver cancer) - raised in CLD, high levels suggest hepatocellular carcinoma
What blood tests would you do to differentiate the cause of Cirrhosis?
Viral serology
α1-antitrypsin
Caeruloplasmin (copper-carrying complex low in Wilson’s)
Iron studies - Serum ferritin, total iron-binding capacity - check for Haemochromatosis
Anti-mitochondrial antibody (PBC)
ANA, ASMA (Autoimmune hepatitis)
Apart from bloods, what other investigations may be useful in Cirrhosis?
Ascitic Tap:
- Microscopy, Culture & Sensitivity - infection
- Biochemistry - Protein, albumin, glucose, amylase
- Cytology
Liver Biopsy:
- Histopathology, Grade & Stage Liver disease
Imaging:
- US, CT, MRI - Look for tumours, thrombosis, biliary obstruction
MRCP: if PSC suspected
OGD: if varices suspected
What is the grading system used to define Chronic Liver Disease/Cirrhosis?
Child-Pugh Grading
Score based on:
- Albumin
- Bilirubin
- PT
- Ascites
- Encephalopathy
Class A/B/C
(C worst)
What is diagnosed if Neutrophils > 250/mm3 in an Ascitic Tap?
Spontaneous Bacterial Peritonitis (SBP)
Generate a general management plan for Cirrhosis:
Treat Cause (if possible)
Avoid alcohol, sedatives, opiates, NSAIDs, and drugs that affect the liver
Ensure nutrition is adequate - NG feeding may be required
Enteral Supplements
Liver Transplant if possible
How would you treat Hepatic Encephalopathy?
Treat cause
Lactuloste and Phosphate enemas
- Lactulose reduces the absorption of ammonia from the gut
- This prevents ammonia crossing the BBB causing toxic effects
Treat infection
Exclude GI bleed
Avoid Sedation
How would you manage Ascites?
Treat Cause
Diuretics (Spironolactone +/- Furosemide)
Sodium restriction
Therapeutic paracentesis (with human albumin replacement)
Monitor weight
Fluid restriction in plasma Na+ < 120 mmol/L
