FN: Cirrhosis

Question 1

Common Causes

Answer 1

􏰁 Chronic EtOH

􏰁 Chronic HCV (and HBV) 􏰁 NAFLD / NASH

Question 2

Other Causes

Answer 2

􏰁 1. Genetic: Wilson’s, α1ATD, HH, CF
􏰁2. AI: AH, PBC, PSC
3. 􏰁 Drugs: Methotrexate, amiodarone, methyldopa,
INH
4. 􏰁 Neoplasm: HCC, mets
􏰁 5. Vasc: Budd-Chiari, RHF, constrict. pericarditis

Question 3

Hand signs of cirrhosis

Answer 3

􏰀 Clubbing (± periostitis)
􏰀 Leuconychia (↓ albumin)
􏰀 Terry’s nails (white proximally, red distally)
􏰀 Palmer erythema
􏰀 Dupuytron’s contracture

Question 4

Face signs of cirrhosis

Answer 4

􏰀 Pallor: ACD
􏰀 Xanthelasma: PBC
􏰀 Parotid enlargement (esp. ̄c EtOH)

Question 5

Trunk signs of cirrhosis

Answer 5

􏰀 Spider naevi (>5, fill from centre)
􏰀 Gynaecomastia
􏰀 Loss of 2O sexual hair

Question 6

Abdo signs of cirrhosis

Answer 6

􏰀 Striae
􏰀 Hepatomegaly (may be small in late disease)
􏰀 Splenomegaly
􏰀 Dilated superficial veins (Caput medusa)
􏰀 Testicular atrophy

Question 7

Complications of cirrhosis

Answer 7

1. Decompensation
2. SBP
3. Portal Hypertension: SAVE
4. Increased risk of HCC

Question 8

Decompensation

Answer 8

Hepatic Failure
􏰀 Jaundice (conjugated)
􏰀 Encephalopathy
􏰀 Hypoalbuminaemia → oedema + ascites
􏰀 Coagulopathy → bruising
􏰀 Hypoglycaemia

Question 9

Portal Hypertension: SAVE

Answer 9

• 􏰀 Splenomegaly
• 􏰀 Ascites
• 􏰀 Varices
  􏰁 1. Oesophageal varices (90% of cirrhotics) 􏰁
  2. Caput medusa
  􏰁 3. Worsens existing piles
• 􏰀 Encephalopathy

Question 10

Bloods show

Answer 10

􏰀 FBC: ↓WCC and ↓ plats indicate hypersplenism 􏰀 ↑LFTs
􏰀 ↑INR
􏰀 ↓Albumin

Question 11

Finding causes of cirrhosis

Answer 11

􏰀1. EtOH: ↑MCV, ↑GGT
􏰀2. NASH: hyperlipidaemia, ↑ glucose
􏰀3. Infection: Hep, CMV, EBV serology
4. Genetic: Ferritin, α1AT, caeruloplasmin (↓ in Wilson’s) 􏰀
5. Autoimmune: Abs (there is lots of cross-over)
6. 􏰀 Ca: α-fetoprotein

Question 12

Antibodies associated AIH

Answer 12

SMA, SLA, LKM, ANA

Question 13

Abs associated with PBC

Answer 13

AMA

Question 14

Abs associated PSC

Answer 14

ANCA, ANA

Question 15

Abs associated with Ig

Answer 15

raised IgG - AIHm raised IgM - PBC

Question 16

Ando US + PV Duplex

Answer 16

􏰀 Small / large liver
􏰀 Focal lesions
􏰀 Reversed portal vein flow 􏰀 Ascites

Question 17

Ascitic Tap + MMCS

Answer 17

􏰀 PMN >250mm3 indicates SBP

Question 18

General Mx

Answer 18

􏰀 􏰀 􏰀 􏰀
Good nutrition
EtOH abstinence: baclofen helps ↓ cravings Colestyramine for pruritus
Screening
􏰁 HCC: US and AFP
􏰁 Oesophageal varices: endoscopy

Question 19

Specific Mx

Answer 19

􏰀 HCV: Interferon-α
􏰀 PBC: Ursodeoxycholic acid
􏰀 Wilson’s: Penicillamine

Question 20

Complications of cirrhosis

Answer 20

􏰀 Varices: OGD screening + banding

􏰀 HCC: US + AFP every 3-6mo

Question 21

Decompesation

Answer 21

􏰀 Ascites: fluid and salt restrict, spiro, fruse, tap, daily wt
􏰀 Coagulopathy: Vit K, platelets, FFP, blood
􏰀 Encephalopathy: avoid sedatives, lactulose ± enemas,
rifaximin
􏰀 Sepsis / SBP: tazocin (avoid gent: nephrotoxicity)
􏰀 Hepatorenal syndrome: IV albumin + terlipressin

Question 22

Classifying Cirrhosis

Answer 22

Child-pugh Grading of cirrhosis

Question 23

Child-pugh Grading of cirrhosis

Answer 23

• Predicts risk of bleeding, mortality and need for Tx
• Graded A-C using severity of 5 factors

􏰁 Albumin
􏰁 Bilirubin
􏰁 Clotting
􏰁 Distension: Ascites 􏰁 Encephalopathy

• Score >8 = significant of variceal bleeding