cirrhosis Flashcards
definition of cirrhosis
end stage of chronic liver damage
replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes
decompensated when complications: ascites, jaundie, encephalopathy, or GI bleeding
aetiology of cirrhosis
chronic alcohol misuse - most common UK cause
chronic viral hep - hep B/C most common worldwide cause
autoimmune hep
drugs - methotrexate, hepatotoxic drugs, amiodarone, methyldopa
inherited
vascular -budd-chiari syndrome or hepatic venous congestion
chronic biliary diseases
cryptogenic - 5-10%
NASH
inherited conditions that cause cirrhosis
a1-antitrypsin deficiency
haemochromatosis
wilson’s disease
galactosaemia
CF
chronic biliary diseases that cause cirrhosis
PBC
PSC
biliary atresia
Non-alcoholic steatohepatitis and cirrhosis
increases risk of developing cirrhosis
NASH is associated with:
- obesity
- dm
- TPN
- short bowel syndromes
- hyperlipidaemia
- drugs - amiodarone, tamoxifen
precipitatants for cirrhosis decompensation
infection
GI bleeding
constipation
high-protein meal
electrolyte imbalances
alcohol and drugs
tumour development
portal vein thrombosis
epidemiology of cirrhosis
among top 10 leading causes of death worldwide
sx of cirrhosis
early non-specific:
- anorexia
- nausea
- fatigue
- weakness
- weight loss
s caused hy reduced liver synthetic function
sx caused by reduced detoxification function
sx of portal HTN
cirrhosis sx caused by reduced liver synthetic function
easy bruising
abdo swelling
ankle oedema
sx of cirrhosis caused by reduced detoxification function
jaundice
personality change
altered sleep pattern
amenorrhoea
sx of cirrhosis caused by portal HTN
abdo swelling
haematemesis
PR bleeding/melaena
signs of cirrhosis
- stigmata of chronic liver disease: asterixis, bruises, clubbing, dupuytren’s contracture, erythema
- jaundice
- gynaecomastia
- atrophic testes
- loss of body hair
- leukonychia
- Terry’s nails - white proximally, distal 1/3 red from telangiectasia
- parotid enlargement (alcohol)
- spider naevi
- scratch marks
- ascites - shifting dullness and fluid thrill
- hepatomegaly - small and shrunken in later stage
- testicular atrophy
- caput medusae
- splenomegaly - portal HTN
- hyperdynamic circulation
- xanthelasma
Ix for cirrhosis
bloods
to determine the cause
ascitic tap
liver biopsy
imaging
endoscopy - examine for varices, portal hypertensive gastropathy
child-pugh grading
bloods for cirrhosis
FBC - low Hb, low WCC and plt - hypersplenism
LFT - may be normal, or - high transaminases, ALP, GGT, BR, low albumin
clotting - prolonged PT (reduced synth of clotting factors)
serum AFP - high in chronic liver disease, V high suggest hepatocellular ca
ix to determine the cause of cirrhosis
viral serology - HBsAg, HBsAb, HCV Ab
immunoglobins
a1-antitrypsin
caeruloplasmin - wilson’s
iron studies - serum ferritin, iron, total iron binding capacity - haemochromatosis
antimitochondrial Ab - PBC
ANA
SMA - autoimmune hep
a-fetoprotein
ascitic tap - cirrhosis
MC&S
biochem - protein, albumin, glucose, amylase
cytology
if neutrophils >250/mm3 - indicates spontaneous bacterial peritonitis
liver biopsy - cirrhosis
percutaneous or transjugular if clotting deranged or ascites present
histopath:
- periportal fibrosis
- loss of normal liver architecture
- nodular
grade - assessment of degree of inflammation
stage - degree of architectural distortion - from mild portal fibrosis -> cirrhosis
imaging for cirrhosis
US, CT, MRI
to detect complications: ascites, hepatocellular ca, hepatic or portal vein thrombosis
to exclude biliary obstruction
MRCP if PSC suspected
US and duplex for cirrhosis
small/large liver
splenomegaly
focal liver lesions
hepatic vein thrombus
reversed flow in portal vein
ascites
MRI for cirrhosis
increased caudate lobe size
smaller islands of regenerating nodules
presence of right posterior hepatic notch
all more in alcoholic than viral
child-pugh grading - cirrhosis
class A - 5-6
class B - 7-9
class C - 10-15
Mx of cirrhosis
treat the cause if possible
avoid alcohol, sedatives, opiates, NSAIDs and drugs that effect the liver
cholestyramine - help pruritis
nutrition is important - if intake is poor need dietition review and enteral supplements
NG feeding might be needed
high dose ursodeoxycholic acid in PBC - may imporve LFT and transplant free survival
penacillamine for wilsons
complications of cirrhosis
Portal HTN with ascites
encephalopathy or variceal haemorrhage
SBP
hepatocellular ca
renal failure - hepatorenal syndrome
pul HTN - hepatopulmonary syndrome
coagulopathy
hypoalbuminaemia - oedema
sepsis - pneumonia, septicaemia
hypoglycaemia
HCC increased risk
Mx for encephalopathy complication of cirrhosis
treat infections
exclude GI bleed
lactulose
phosphate enemas
avoid sedation
prophylactic lactulose and rifaximin
Mx of ascites complication of cirrhosis
diuretics - spirinolactone +- furosemide
sprinolactone counters deranged RAAS system
dietary Na restriction 88meq or 2g/day
therapeutic paracentesis - human albumin replavement IV
monitor weight daily
fluid restriction in pts with plasma Na <120mmol/L
avoid alcohol and NSAIDs
chart daily weight and aim for weight loss 0.5kg/day
Mx of spontaneous bacterial peritonitis (SBP) complication of cirrhosis
considered in any pt with ascites that deteroirates quickly - may be asymptomatic
AB - cefuroxime and metronidazole
prophylaxis against recurrent SBP with ciprofloxacin for high risk pts (low albumin, high PT/INR, low ascitic albumin), or if had previous episode
common organisms - E coli, klebsiella, streptococci
surgical Mx of complications of cirrhosis
consider TIPS to relieve portal HTN of recurrent variceal bleeds or diuretic-resistant ascites
- may precipitate encephalopathy
liver transplant is only cure
Px of cirrhosis
depends on the aetiology and complications
generally poor - 5yr surival 50%
if ascites 2yr survival 50%
Poor prognostic indicators: encephalopathy; serum Na+ <110mmol/L; serum albumin <25g/L; high INR.
what is hepatorenal syndrome
cirrhosis + ascitis + renal failure - if other causes of renal failure have been excluded
abnormal haemodynamics -> splanchnic and systemic vasodilation, but renal vasoconstriction
bacterial translocation, cytokines and mesentaric angiogenesis -> splanchnic vasodilation, and altered renal autoregulation is involved in renal vasoconstriction
complications of cirrhosis caused by portal HTN
ascites
splenomegaly
portosystemic shunt includinhg oesophageal varices +- life threatening upper GI bleed
caput medusae
follow up Mx of cirrhosis
consider US +- a-fetoprotein every 6mo to screen for HCC - when that info would change mx
how does cirrhosis cause renal failure
reduced hepatic clearance of immune complexes = trapping in kidneys (=IgA nephropathy +- hepatic glomerulosclerosis
