Cirrhosis (GI) Flashcards
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
- Bruising
- Clubbing
- Dupuytren’s contracture
- Erythema (palmar)
- 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
What test is recommended for patients with non-alcoholic fatty liver disease?
Using enhanced liver fibrosis score to screen for patients who need further testing
What other scans are done for investigating cirrhosis? (2)
- upper GI endoscopy - check for varices in patients with new cirrhosis diagnosis
- liver US (and AFP) every 6 months - to check for hepatocellular cancer
What do LFTs show in liver cirrhosis?
- deranged - AST and ALT increase with hepatocellular damage
- normally ALT > AST - except for alcohol-related liver disease
- ALD –> AST:ALT = 2:1
What does serum albumin show in cirrhosis?
Reduced - marker of hepatic synthetic dysfunction
What does prothrombin time show in cirrhosis?
Prolonged - marker of hepatic synthetic dysfunction
What does serum sodium show in cirrhosis?
Reduced - common finding in cirrhotic patients with ascites as they are hypovolaemic and hyponatraemic
What are platelets like in cirrhosis?
Reduced as portal HTN –> hypersplenism + platelet sequestration
What is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease?
Thrombocytopenia (platelet count <150,000mm3)
How do we diagnose SBP (cirrhosis)?
Paracentesis - neutrophil count >250cells/ul
What are some differential diagnoses for cirrhosis? (10)
- Budd-Chiari syndrome (abdominal pain, diarrhoea, progressively worsening ascites)
- portal vein thrombosis (Sx of underlying cause e.g. chronic pancreatitis, ascending cholangitis, abdominal sepsis)
- splenic vein thrombosis (Sx of pancreatitis)
- nodular regenerative hyperplasia
- idiopathic portal hypertension
- constrictive pericarditis (raised JVP, tachycardia, AF, S3)
- IVC obstruction (Sx of renal cell carcinoma)
- schistosomiasis
- sarcoidosis
- vitamin A intoxication, arsenic and vinyl chloride toxicity
What is the principle of cirrhosis management?
Treatment of underlying chronic liver disease/cause and prevention of superimposed hepatic insult
What do we recommend if liver disease is alcoholic?
Abstinence from alcohol and good nutrition
What are some hepatotoxic drugs to avoid in liver disease/cirrhosis? (4)
- NSAIDs
- paracetamol
- methotrexate
- amiodarone
How do we manage liver cirrhosis with encephalopathy?
- lactulose - reduces ammonia absorption from gut
- secondary prophylaxis - rifaximin
How do we manage ascites in cirrhosis? (3)
- sodium restriction
- diuretic - spironolactone
- paracentesis to drain
How do we manage spontaneous bacterial peritonitis (cirrhosis)?
Prophylactic Abx (ciprofloxacin or norfloxacin)
What surgeries can we do if complications of cirrhosis or signs of decompensation? (2)
- liver transplant
- transjugular intrahepatic portosystemic shunt (TIPS) - to reduce portal hypertension - if not suitable for liver transplant
What does transjugular intrahepatic portosystemic shunt (TIPS) reduce the risk of?
Oesophageal varices secondary to portal hypertension
How do we manage oesophageal varices secondary to portal hypertension?
- IV terlipressin (vasoactive agent - vasopressin analogue)
- IV Abx
- vitamin K
- blood transfusion if Hb<7g/dL
- prophylaxis: propranolol, endoscopic variceal band ligation with PPI
- Sengstaken-Blakemore tube if uncontrolled haemorrhage
- TIPS if others fail
How do we monitor complications in cirrhosis? (3)
- abdominal US - ascites
- upper GI endoscopy - gastro-oesophageal varices
- USS, CT, MRI - hepatocellular carcinoma detection
What are some complications of cirrhosis?
- ascites
- gastro-oesophageal varices which may rupture (enlarged veins –> caput medusae)
- hepatocellular carcinoma
- bleeding and thrombosis (from varices/deranged clotting/HCC)
- spontaneous bacterial peritonitis (neutrophils>250cells/mm3, Abx prophylaxis if risk)
- hepatic encephalopathy (give lactulose)
- hepatorenal syndrome
- hypogonadism and feminisation
Describe the overall prognosis of cirrhosis.
Overall median survival is 10 years but prognosis depends on stage of disease
