Hepato-biliary: Cirrhosis Flashcards
What is cirrhosis?
Cirrhosis is defined anatomically by the presence throughout the liver of fibrous septa that subdivide the parenchyma into nodules.
What are causes of cirrhosis?
- Chronic alcohol abuse
- Viral hepatitis - HBV, HCV
-
Autoimmune
- Autoimmune hepatitis
- PSC, PBC
-
Metabolic liver disease
- Haemochromatosis
- A1-antitrypsin
- Wilson’s disease
- Drugs - amiodarone, methyldopa, methotrexate
- Budd-chiari
- Cystic fibrosis
- Non-alcoholic steatohepatitis
What are signs of liver cirrhosis?
- Abdo distension seconadry to ascites in portal hypertension and hepatomegaly
- Jaundice and pruritis
- Coffee ground vomitus and black stool secondary to GI haemorrhage from gastroesophageal varices
-
Hand and nail feautres
- Leuconychia
- Terry’s nails
- Clubbing
- Palmar erythema
- Dupuytren’s contracture
- Bruises
- Cholesterol deposits in palmar creases (PBC)
-
Facial features
- Telandiectasia
- Spider angioma
- Parotid gland swelling
- Thinning skin
- Red tongue (alcohol)
- Sebhorreic dematitis
- Jaundice sclera
- Xanthelasma
-
Abdo features
- Caput medusae
- Bruising
- Hepatomegaly
- Splenomegaly
- Abdo distension
- Shgting dullness/fluid thrills secondary to ascite
-
Other signs
- Hyperdynamic circulation
- Gynaecomastia
- Atrophic testes
- Loss of body hair
- Small liver - late disease
What are symptoms of liver cirrhosis?
-
Early
- Weight loss
- Anorexia
- Nausea
- Fatigue
- Weakness
-
Reduced snthetic function
- Easy rbuising
- Abdominal swelling/distension
- Ankle oedema
-
Reduced detoxifying function
- Jaundice
- Personality change
-
Other
- Right hypochondrial pain due to liver distension
- Altered mental status
- Pruritis
- Haematemesis/malaena
- Leg swelling
- Gynaecomastia
- Loss of libido
- Amenorrhoea
What are complications of liver cirrhosis?
- Hepatic failure
- Portal hypertension
- Ascites
- Spontaneous bacterial peritonitis
- Enchephalopathy
- Renal failure
- HCC
What are risk factors for the development of cirrhosis?
- Alcohol misuse
- IVDU
- Unprotected intercourse
- Obesity
- Blood transfusion
- Tatooing
What is the pathogenesis of cirrhosis?
Chronic injury to the liver results in inflammation, necrosis and, eventually, fibrosis Fibrosis is initiated by activation of the stellate cells. Kupffer cells, damaged hepatocytes and activated platelets are probably involved.
What are the pathological features of cirrhosis?
Characteristic features of cirrhosis are regenerating nodules separated by fibrous septa and loss of the normal lobular architecture within the nodules
What are pathological features of micronodular cirrhosis?
Regenerating nodules are usually <3 mm in size and the liver is involved uniformly
What are causes of micronodular cirrhosis?
- Alcohol misuse
- Biliary tract disease
What are pathological features of macronodular cirrhosis?
The nodules are of variable size and normal acini may be seen within the larger nodules
What is often the cause of macronodular cirrhosis?
Chronic viral hepatitis
What are features of hepatic failure?
- Coagulopathy
- Encephalopathy
- Hypoalbuminaemia
- Sepsis
- Spontaneous bacterial peritonitis
- Hypoglycaemia
What is portal hypertension?
Partial/complete obstruction of portal blood to liver
Portal venous system takes blood from GI tract to liver to be cleansed before returning to heart.
Systemic circulation is blood returning to heart.
In portal hypertension, blood should flow to the liver but due to changes in pressure the blood joins systemic circulaton leading to:
Oesophageal varices
Caput medusae
Anorectal varices/haemorrhoids
What are features of portal hypertension in someone with cirrhosis?
- Ascites
- Splenomegaly
- Portosystemic shunt - including oesophageal varices
- Caput medusae
- GI bleed
- Hepatic encephalopathy
Explain complications of portal hypertension
-
Oesophageal varices
- Varices are weakened vessles due to stretching of their walls
- Systemic vessles are weaker so expand
- V dangerous
- Black and tarry stools
- Could be medical emergency
-
Caput medisae
- Swollen veins on abdo that radiate from umbillicus
- Round ligament of liver is the reminant of the umbillical vein. It maintains shape of the lumen.
- PHT can reopen this channel causing blood flow to veins of periumbilical region.
-
Anorectal varices/haemarrhoids
- Superior rectal vein is the only one that contributes to portal circulation
- Anastomoses between superior, middle and inferior veins leads to varices
- Not usually painful due to viceral innervation
Where are sites of portosystemic anastomoses
Oesophageal -haematemesis
Rectal - haematochezia
Para-umbillical -rectal bleeding
Retro-peritoneal
What investigations would you consider doing in someone you suspected had liver cirrhosis?
-
Bloods
- LFT, FBC, Clotting, Albumin, glucose
- Find the cause - hepatitis serology, iron studies, immunoglobulins, autoantibodies, A-fetoprotein, copper + caeruloplasmin (<40 yrs), A1-antitrypsin
- Liver US + duplex
- MRI
- Ascitic tap
- Consider endoscopy
- Liver biopsy
What might you see on LFT in someone with cirrhosis?
Normal LFTs, or
- Increased Bilirubin
- Increased AST
- Increased ALT
- Increased ALP
- Increased GGT
When would synthetic dysfunction of the liver (i.e. albumin production, clotting factors) occur in cirrhosis?
Late feature of cirrhosis
What might you see on FBC in someone with cirrhosis?
Features of hyposplenism
- Decreased WCC
- Thrombocytopenia
What autoantibodies would you be looking for in someone with suspected cirrhosis?
- ANA
- AMA
- SMA
What might you find on Liver US + duplex scan?
- Small liver/Hepatomegaly
- Splenomegaly
- Focal liver lesions
- Hepatic vein thrombosis
- Reversed flow in portal vein
- Ascites
What might you see on MRI in someone with suspected cirrhosis?
- Increased caudate lobe size
- Smaller islands of regenerating nodules
What can be used to control uncontrolled variceal bleeding?
- Trans-jugular intrahepatic porto-systemic shunt (TIPS)
- Balloon tamponade - Sengstaken-Blakemore tube - compresses the varcies
