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
Why might you do iron studies in someoen with suspected cirrhosis?
Look for hereditary haemochromatosis
What might you see on U+E’s in someone with cirrhosis?
Hyponatraemia - indicates severe liver disease due to defect in free water clearence/excess diuretic therapy
What can a raised A-fetoprotein (>200 ng/mL) indicate in someone with cirrhosis?
Hepatocellular carcinoma
What might a raised copper and low caeruloplasmin indicate?
Wilson’s disease as cause of cirrhosis
What are indications for liver transplant in someone with cirrhosis?
- Acute liver failure
- Advanced cirrhosis - signs of decompensation, jaundice, variceal haemorrhage, post systemic encephalopathy or hepatorenal syndrome
- Hepatocellular cancer
Must be T total for 2 years
Why might you consider doing endoscopy in someone with cirrhosis?
Detection and treatment of:
- Oesophageal varices
- Portal hypertensive gastropathy
What is involved in a ascitic tap?
Aspiration of ascitic fluid
Why does ascites occur in cirrhosis?
- Sodium and water retention - peripheral arterial vasodilatation and consequent reduction in the effective blood volume
- Portal hypertension - local hydrostatic pressure and leads to increased hepatic and splanchnic production of lymph and transudation
- Low serum albumin - reduction in plasma oncotic pressure.
What investigations would you perform on ascitic fluid?
- Cell count
- Gram stain and culture
- Serum ascites-albumin gradient
- Cytology
What would a serum ascites-albumin gradeint of > 1.1g/dl indicate as the cause of ascites?
Portal HTN related
- Portal hypertension
- CHF
- Constrictive pericarditis
- Budd Chiarri
- Myxedema
- Massive liver metastases
What would a serum ascites-albumin gradeint of < 1.1g/dl indicate as the cause of ascites?
Non-portal HTN related
- Malignancy
- Tuberculosis
- Chylous ascites
- Pancreatic
- Biliary ascites
- Nephrotic syndrome
- Serositis
How would you generally manage someone with cirrhosis?
- Specific treatment for cause
- Good nutrition
- Alcohol abstinence
- Avoid NSAIDs, sedatives, and opiates
- Consider HCC monitoring - A-fetoprotein + ultrasound
How would you manage someone with ascites as a complication of liver cirrhosis?
- Fluid restriction <1.5 L/day
- Low salt diet
- Spironolactone
- Monitor weight
- Consider diuretics if poor response
- Consider therapeutic paracentesis
What do you need to consider in someone with ascites who deteriorates suddenly?
Spontaneous bacterial peritonitis
What are common organisms implicated in spontaneous bacterial peritonitis?
- E. Coli
- Klebsiella
- Streptococci
What investigations sould you consider doing if you suspected spontaneous bacterial peritonitis?
Paracentesis
How would you manage someone with spontaneous bacterial peritonitis?
- Antibiotics - Pip/Taz until sensitivities known
- Ascitic fluid drainage
- IV albumin infusion
What are features of grade 1 hepatic encephalopathy?
- Sleep reversal
- Altered mood/behaviour
- Mild lack of awareness/Shortened attention span
- Impaired computations
- Dyspraxia - 5 point star
What are features of grade II hepatic encephalopathy?
- Increasing drowsiness/lethargy
- Confusion
- Slurred speech
- May have liver flap
- Personality change
What are features of grade III hepatic encephalopathy?
- Somnolence/Stuporous
- Confusion/disorientation/Incoherent
- Restless
- Asterixis
- Hyperreflexia
- Nystagmus
- Clonus
- Rigidity
What are features of grade IV hepatic encephalopathy?
Coma
How does hepatic encephalopathy occur?
As liver fails, nitrogenous waste builds up in the circulation and passes into the brain, where astrocytes clear it (by processes involving the conversion of glutamate to glutamine).
Excess glutamine causes an osmotic imbalance and a shift of fluid into these cells, leading to cerebral oedema
How would you manage hepatic encephalopathy as a complication of acute/decompensated liver failure?
- 20o head-up tilt in ITU
- Avoid sedatives
- Correct electrolytes
- Lactulose
- Rifaximin
Why might you use lactulose in someone with hepatic encephalopathy?
It is catabolised by bacterial flora to short chain fatty acids which decrease colonic pH and trap NH3 in the colon as NH4+
Why might you use Rifaximin in management of hepatic encephalopathy?
Non-absorbable antibiotic that decreases numbers of nitrogen forming bacteria in the gut
What factors can increase the risk decompensated lvier failure in someone with cirrhosis?
- Dehydration
- Constipation
- Covert alcohol use
- Infection
- Opiate overuse
- Occult GI bleed
- Portal vein thrombosis
What are pre-hepatic causes of portal hypertension?
Portal venous thrombosis
What are intrahepatic causes of portal hypertension?
- Schistosomiasis
- Sarcoidosis
- PBC
- Cirrhosis
- Veno-occlusive disease
- Budd chiari syndrome
What are post-hepatic causes of portal hypertension?
- Right heart failure
- Constrictive pericarditis
- IV obstruction
How would you investigate portal hypertension?
HVPG measurement of >5mmHg
How would you manage a varcieal bleed?
- IV Terlipressin - vasopressin drug, reduces portal inflow
- Broad-spectrum IV antibiotics
- Endotherapy - variceal ligation (band ligation)/Sclerotherapy
- Correct any coagulopathies
- Baloon tamponade - if endoscopic therapy failed - balloon in stomach against GU junction (could cause perf of oesophagus, aspiration, mortality 20%)
What can be used to control uncontrolled variceal bleeding?
- Trans-jugular intrahepatic porto-systemic shunt (TIPS)
- Balloon tamponade - Sengstaken-Blakemore tube - compresses the varcies
What is done for prevention of recurrent bleed of variceal haemorrhage
Medical - beta blocker and follow up endoscopic screening (endoscopic variceal ligation)
Surgical - TIPs, liver transplant
Important lifestyle advice liver cirrhosis
Important of weight loss/good nutrition
Avoidance of alcohol, NSAIDs and high dose paracetamol
Complications of cirrhosis
- Ascites
- Portal hypertension
- Variceal haemorrhage
- Hepatic encephaloapthy
- Hepatorenal syndrome
- HCC
- Malnutrition
- Osteoporosis
- Vit deficiency (esp B1)
- Infection - impaired immune system
- Coagulopathy
What is hepatorenal syndrome?
Development of renal failure in patients with severe liver disease (acute/chronic) in absense of other renal pathology
- Systemic vasodilation leads to decreased BP
- Activation sympathetic NS - vasoconstriction and altered renal autoregulation, such that renal blood flow is much more dependant on MAP
- Leads to pre-renal AKI
How does cirrhosis lead to:
a) Ascites
b) Hepatorenal syndrome
c) Decreased Na
Cirrhosis
PHT
Splanchnic vasodilation
Decreased circulating volume (GI haemorrhage, diarrhoea, over diuresis)
Activation of RAAS system
Leads to…
Renal sodium activity: ascites
Renal vasoconstriction: Hepatorenal syndrome
Water retention: Decreased Na
