Cirrhosis Flashcards
What is cirrhosis?
End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis + nodules of regenerating hepatocytes.
When is cirrhosis considered decompensated?
Once it becomes complicated by: Ascites Jaundice Encephalopathy GI bleed
List 8 causes of cirrhosis
Chronic alcohol misuse (most common in UK)
Chronic viral hepatitis (hep B/C: most common worldwide)
AI hepatitis
Drugs (e.g. methotrexate, hepatotoxic drugs)
Inherited
Vascular: Budd-Chiari Syndrome, Hepatic Venous Congestion
Chronic Biliary Diseases: PBC, PSC, Biliary atresia
Unknown: 5-10%
Non-Alcoholic Steatohepatitis (NASH)
What things may precipitate decompensation?
Infection GI bleeding Constipation High-protein meal Electrolyte imbalances Alcohol + drugs Tumour development Portal vein thrombosis
Describe the epidemiology of cirrhosis
In top 10 causes of death worldwide
List 5 early non-specific symptoms in cirrhosis
Anorexia Weight loss Nausea Fatigue Weakness
List 3 symptoms caused by reduced liver synthetic function
Easy bruising
Abnormal swelling
Ankle oedema
List 5 symptoms caused by reduced detoxification function
Jaundice Personality change Altered sleep pattern Amenorrhoea Galactorrhoea
List 3 symptoms caused by portal HTN
Abdominal swelling
Haematemesis
PR bleeding or melaena
What are the ABCDE signs in cirrhosis?
Asterixis Bruises Clubbing Dupuytren's contracture Palmar erythema
List 11 signs of cirrhosis
Jaundice Gynaecomastia Leukonychia Parotid enlargement Spider naevi Scratch mark (from cholestatic pruritis) Ascites (shifting dullness) Enlarged liver (shrunken in later stages) Testicular atrophy Caput medusae Splenomegaly
What bloods should be investigated in cirrhosis?
FBC: low platelets + Hb = because of hypersplenism due to portal HTN
LFTs: some normal, but often get:
High AST, ALT, ALP, GGT + BR
Low albumin
Clotting: prolonged PT (decreased synth of clotting factors)
Serum AFP (tumour marker for liver cancer):
Raised in chronic liver disease but high levels may suggest hepatocellular carcinoma
Why should an Ascitic Tap be performed in cirrhosis?
MC+S : check for infection
Biochemistry (protein, albumin, glucose, amylase)
Cytology
If neutrophils > 250/mm3 = spontaneous bacterial peritonitis (SBP)
Which method of liver biopsy is used in cirrhosis? What are the histopathological features?
Percutaneously Transjugular (if clotting deranged or ascitic)
Periportal fibrosis Loss of normal liver architecture Nodular appearance Grade: degree of inflammation Stage: degree of architectural distortion (from mild portal fibrosis to cirrhosis)
What imaging should be performed in cirrhosis?
US, CT or MRI: to detect Ascites, HCC, Hepatic or portal vein thrombosis + Exclude biliary obstruction
MRCP (if PSC suspected)
What may be found on endoscopy in cirrhosis?
Varices
Portal hypertensive gastropathy
What grading system is used to estimate prognosis in cirrhosis?
Child-Pugh Grading A-C: based on 5 factors: Albumin BR PT Ascites Encephalopathy
How is cirrhosis managed?
Treat the CAUSE if possible Avoid alcohol, sedatives, opiates, NSAIDs + drugs that affect the liver Nutrition is important Enteral supplements should be given NG feeding may be indicated
How is encephalopathy treated?
Treat infections
Exclude GI bleed
Use lactulose + phosphate enemas
Avoid sedation
How is ascites treated?
Diuretics (spironolactone +/- furosemide)
Dietary sodium restriction
Therapeutic paracentesis (with human albumin replacement)
Monitor weight
Fluid restrict if plasma Na+ < 120 mmol/L
Avoid alcohol + NSAIDs
How is SBP treated?
Abx (e.g. cefuroxime + metronidazole)
Prophylaxis against recurrent SBP with ciprofloxacin
What surgical intervention may be used in cirrhosis to reduce portal HTN? What is the issue with this?
TIPS (transjugular intrahepatic portosystemic shunt) to reduce portal HTN
May precipitate encephalopathy as provides a route for blood from GIT to bypass the liver
List 7 complications of cirrhosis
Portal HTN with ascites Hepatic encephalopathy Variceal haemorrhage SBP HCC Renal failure (hepatorenal syndrome) Pulmonary HTN (hepatopulmonary syndrome)
What is the prognosis in cirrhosis?
Depends on aetiology + complications
Generally poor prognosis
Overall 5 year survival = 50%
If ascites, 2 year survival = 50%
List 5 inherited diseases that can lead to cirrhosis
a1-antitrypsin deficiency Haemochromatosis Wilson's disease Galactosaemia Cystic Fibrosis
List 6 risk factors for NASH
Obesity Diabetes Total parenteral nutrition Short bowel syndromes Hyperlipidaemia Drugs (e.g. amiodarone, tamoxifen)
What investigations can be used to determine the cause of cirrhosis?
Viral serology (hep B + C) a1-antitrypsin Caeruloplasmin (LOW in Wilson's) Iron studies: serum ferritin, iron, total iron binding capacity (TIBC): for haemochromatosis Anti-mitochondrial antibody (PBC) ANA SMA (AI hepatitis)
How does encephalopathy arise in cirrhosis? How does lactulose treat this?
Normal liver breaks down ammonia absorbed in GIT
In Cirrhosis, ammonia goes through liver without being broken down + exerts toxic effects on the brain
Lactulose reduces absorption of ammonia from gut
Helps prevent encephalopathy caused by ammonia reaching the brain
What is the only curative method for cirrhosis?
Liver transplant
