Cirrhosis (GI) Flashcards by Savita Ramkumar

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

How well did you know this?

Not at all

Perfectly

Who does cirrhosis occur more in?

M>F 2:1

How well did you know this?

Not at all

Perfectly

What causes the bumpy texture of a cirrhotic liver?

Liver cells come together to form regenerative nodules separated by fibrotic scar tissue

How well did you know this?

Not at all

Perfectly

Is liver scarring in cirrhosis reversible?

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

Why do we get abdominal distension in cirrhosis?

Decompensated cirrhosis secondary to reduced hepatic excretion of conjugated bilirubin

How well did you know this?

Not at all

Perfectly

What do jaundice and pruritus in cirrhosis suggest?

Decompensated cirrhosis secondary to reduced hepatic excretion of conjugated bilirubin

How well did you know this?

Not at all

Perfectly

What do haematemesis and melaena suggest in cirrhosis?

Decompensated cirrhosis secondary to GI haemorrhage due to varices

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What hand and nail features are seen on examination in cirrhosis? (4)

leukonychia (hypoalbuminaemia)
palmar erythema
clubbing
Dupuytren contracture (alcohol-related liver disease)

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What two scoring systems can be used to determine cirrhosis severity?

Child-Pugh classification
MELD (Model for End-stage Liver Disease)

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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