Cirrhosis (GI) Flashcards
(46 cards)
Define cirrhosis.
Pathological end stage of any chronic liver disease, characterised by fibrosis and conversion of normal liver architecture to structurally abnormal nodules called regenerative nodules
Who does cirrhosis occur more in?
M>F 2:1
What causes the bumpy texture of a cirrhotic liver?
Liver cells come together to form regenerative nodules separated by fibrotic scar tissue
Is liver scarring in cirrhosis reversible?
No
What can cirrhosis lead to?
Portal hypertension, liver failure + hepatocellular carcinoma
- damaged hepatocytes lining perisinusoidal space activate stellate cell –> TGF-b secretion –> collagen production –> fibrosis
- fibrotic tissue compresses sinusoids and vessels –> portal hypertension + reduced liver function
- portal htn –> fluid pushed out of veins and sinusoids –> fluid in peritoneal cavity = ascites + splenomegaly (as fluid backs into spleen)
- can cause a porto-systemic shunt where high pressures divert blood away from liver and favours systemic circulation
- reduced detoxification by liver –> toxin accumulation in brain –> hepatic encephalopathy (mainly ammonia)
What are the common causes of cirrhosis? (3)
- alcohol-related liver disease (ALD)
- non-alcoholic fatty liver disease (NAFLD)
- chronic viral hepatitis (B and C)
What are the clinical features of cirrhosis? (10)
- abdominal distension
- jaundice and pruritus
- haematemesis and melaena (haemorrhage due to varices)
- encephalopathy
- hand and nail features (leukonychia, palmar erythema, clubbing, Dupuytren contracture)
- spider naevi (>4, fill from centre)
- gynaecomastia (reduced oestrogen metabolism)
- hepatomegaly and splenomegaly
- hepatic fetor - sweet putrid breath
- muscle wasting and anorexia (malnutrition and hypercatabolism)
Why do we get abdominal distension in cirrhosis?
Decompensated cirrhosis secondary to reduced hepatic excretion of conjugated bilirubin
What do jaundice and pruritus in cirrhosis suggest?
Decompensated cirrhosis secondary to reduced hepatic excretion of conjugated bilirubin
What do haematemesis and melaena suggest in cirrhosis?
Decompensated cirrhosis secondary to GI haemorrhage due to varices
Why do we get encephalopathy in cirrhosis and what can this lead to?
Due to excess ammonia, can lead to:
- confusion
- altered GCS
- asterixis - inability to maintain sustained posture with subsequent brief, shock-like, involuntary movements
What hand and nail features are seen on examination in cirrhosis? (4)
- leukonychia (hypoalbuminaemia)
- palmar erythema
- clubbing
- Dupuytren contracture (alcohol-related liver disease)
What facial features are seen on examination in cirrhosis? (8)
- telangiectasia
- spider naevi (>4 and fill from centre)
- jaundiced sclera
- rhinophyma
- parotid gland swelling
- paper money skin appearance
- red tongue
- seborrhoeic dermatitis
What abdominal features are seen on examination in cirrhosis? (6)
- collateral circulation
- hepatosplenomegaly
- distension, shifting dullness, fluid thrill (ascites due to portal htn)
- caput medusae
- bruising
- loss of secondary sexual hair + testicular and breast atrophy
What is the A-J of liver failure/cirrhosis?
- Asterixis + ascites
- Bruising
- Clubbing
- Dupuytren’s contracture
- Erythema (palmar) + encephalopathy
- Fetor hepaticus (strong smelly breath)
- Gynaecomastia
- Hepatomegaly + Hair loss
- Itching + Icterus
- Jaundice + JVP
What are the clinical features of portal hypertension? (4)
- ascites
- splenomegaly
- caput medusae - cluster of swollen veins in abdomen
- causes swelling of veins (varices) in oesophagus and rectum
What two scoring systems can be used to determine cirrhosis severity?
- Child-Pugh classification
- MELD (Model for End-stage Liver Disease)
What is an easy way to remember the Child-Pugh scoring system for cirrhosis severity?
ABCDE; each parameter scored 1,2,3
- Albumin - lower the worse (>35, 28-35, <28)
- Bilirubin - higher the worse, and same for rest (<34, 34-51, >51)
- Clotting - PT (<4, 4-6, >6)
- Distension - ascites
- Encephalopathy
Graded A B or C:
- A: <7
- B: 7-9
- C: >9
What is the MELD score for cirrhosis severity?
MELD = 3.8xln[serum bilirubin] + 11.2xln[INR] + 9.57xln[serum creatinine] + 6.43
The higher the score, the higher the mortality:
- 40+: 71.3%
- 30-39: 52.6%
- 20-29: 19.6%
- 10-19: 6.0%
- <9: 1.9%
What are some risk factors for cirrhosis? (7)
- alcohol misuse –> ALD
- obesity –> NAFLD
- IVDU –> hep B&C
- unprotected intercourse –> hep B&C
- blood transfusion –> hep B&C
- country of birth –> endemic hep B&C
- tattoos
What are the first-line investigations for cirrhosis? (3)
- LFTs
- liver biopsy
- transient elastography - evidence of fibrosis without biopsy
What is the most specific and sensitive investigation for cirrhosis?
Liver biopsy
What are the adverse effects of a liver biopsy to diagnose cirrhosis?
Bleeding and pain
What other techniques are now used more than liver biopsy in diagnosing cirrhosis? (2)
- transient elastography - named ‘Fibroscan’ and passes 50MHz wave into liver to measure stiffness and fibrosis
- acoustic radiation force impulse imaging
