Liver Cirrhosis Flashcards
Why does liver cirrhosis occur?
- it is the result of chronic inflammation that damages the liver cells
- damaged liver cells are replaced with scar tissue (fibrosis)
- nodules of scar tissue form within the liver
Why does portal hypertension occur in cirrhosis?
- fibrosis affects the structure and blood flow through the liver
- there is increased resistance in the vessels leading to the liver
- this results in an increased pressure in the portal system
What are the most common causes of cirrhosis?
- hepatitis B
- hepatitis C
- alcoholic liver disease
- non alcoholic fatty liver disease
What are some of the rarer causes of cirrhosis?
- autoimmune hepatitis
- primary biliary cirrhosis
- haemochromatosis
- Wilsons disease
- alpha-1 antitrypsin deficiency
- cystic fibrosis
- drugs
it is important to consider these as some of them are potentially reversible
Which drugs can potentially cause cirrhosis?
- S - sodium valproate
- A - amiodarone
- M - methotrexate
remember - SAM
What are the signs of cirrhosis?
- jaundice (raised bilirubin)
- caput medusae (portal HTN)
- palmar erythema (hyperdynamic circulation)
- gynaecomastia / testicular atrophy (endocrine dysfunction)
- bruising (abnormal clotting)
- ascites
- spider naevi
- hepatomegaly (but liver then shrinks as it becomes more cirrhotic)
- splenomegaly (portal HTN)
- asterixis (in decompensated disease)
What are spider naevi?
telangiectasia with a central arteriole and small vessels radiating away
telangiectasia (“spider veins”) - dilated / broken blood vessels near the surface of the skin
What blood tests are performed in cirrhosis?
LFTs:
* usually normal
- all markers become deranged in decompensated disease (ALP, AST, ALT + bilirubin)
albumin + prothrombin time:
- markers of synthetic function
- low albumin and raised PTT is seen
U&Es:
- hyponatraemia indicates fluid retention in severe disease
urea + creatinine:
- deranged in hepatorenal syndrome
alpha-fetoprotein:
- tumour marker for HCC
Why is alpha-fetoprotein (AFP) measured in cirrhosis?
- it is a tumour marker for hepatocellular carcinoma
- it should be checked every 6 months with USS
- this is a screening test for HCC
What is the enhanced liver fibrosis (ELF) blood test?
When is it used?
- first line investigation for assessing fibrosis in NAFLD
- cannot be used for diagnosing cirrhosis of other causes
it is currently not available in many areas
How can the ELF score be used to determine whether fibrosis is present?
- a score < 7.7 indicates no or mild fibrosis
- a score 7.7 - 9.8 indicates moderate fibrosis
- a score of 9.8 or higher indicates severe fibrosis
it measures 3 markers - HA, PIIINP and TIMP-1
What may be seen on ultrasound in cirrhosis?
- nodularity of the surface of the liver
- “corkscrew” appearance of arteries with increased flow
- enlarged portal vein with reduced flow
- ascites
- splenomegaly
When is a patient with cirrhosis offered an USS?
- NICE recommend AFP + USS every 6 months in patients with cirrhosis
- this screens for HCC
What is FibroScan and what does it test for?
- it checks the elasticity of the liver by sending high frequency sound waves into it
- this assesses the degree of cirrhosis
it is called “transient elastography”
How frequently should a FibroScan be performed?
- it should be performed every 2 years in patients at risk of cirrhosis
- hepatitis C
- heavy alcohol drinkers
- NAFLD + evidence of fibrosis on ELF test
- alcoholic liver disease
- it should be performed yearly in chronic hepatitis B
heavy alcohol drinkers = > 50 units for men and > 35 units for women per week
When is endoscopy performed in cirrhosis?
to assess for and treat oesophageal varices if portal hypertension is suspected
When may CT and MRI scans be performed in cirrhosis?
to look for:
- hepatocellular carcinoma
- hepatosplenomegaly
- ascites
- abnormal blood vessel changes
What test is needed to make a definitive diagnosis of cirrhosis?
liver biopsy
What score is used to indicate the severity of cirrhosis?
Child-Pugh score
indicates severity of cirrhosis and prognosis
What parameters are used to calculate the Child-Pugh score?
- encephalopathy
- INR
- bilirubin
- albumin
- ascites
- each parameter is given a score of 1, 2 or 3
(remember parameters as EIBAA)
What is the MELD score and when is it used?
- it is used every 6 months in patients with compensated cirrhosis
- it assesses whether they require dialysis
- it gives a 3-month estimated mortality which helps guide referral for liver transplant
What parameters are included in the MELD score?
- bilirubin
- INR
- creatinine
- sodium
remember parameters as BICS
What stages are involved in the general management of cirrhosis?
- USS + AFP every 6 months to assess for HCC
- MELD score every 6 months
- high protein and low sodium diet
- endoscopy every 3 years (in patients without known varices)
- consider liver transplant
- manage complications
How is the prognosis of cirrhosis estimated?
- through use of the Child-Pugh and MELD scores
- disease course is variable
- 5-year survival is around 50%
What are the potential complications of cirrhosis?
- malnutrition
- hepatorenal syndrome
- ascites + spontaneous bacterial peritonitis
- hepatic encephalopathy
- hepatocellular carcinoma
- portal hypertension, varices + bleeding
Why is a liver biopsy no longer recommended by NICE as a diagnostic tool for cirrhosis?
- the procedure is associated with adverse effects, such as bleeding and pain
- FibroScan and imaging are used instead
- ELF score is used in NAFLD
Why does malnutrition occur in cirrhosis and what are the consequences of this?
- cirrhosis affects metabolism of proteins in the liver, reducing the amount of protein produced
- it affects the ability to store glucose as glycogen, leading to use of muscle tissue as fuel
- this leads to muscle wasting + weight loss
How is malnutrition as a result of cirrhosis managed?
- regular meals (every 2-3 hours)
- low sodium diet (to minimise fluid retention)
- high protein + high calorie diet
- avoid alcohol
What is the portal vein formed from?
What happens in portal hypertension?
- the portal vein is formed from the superior mesenteric vein and splenic vein
- in cirrhosis there is increased resistance to blood flow in the liver
- this leads to increased back-pressure in the portal system
How does portal hypertension result in varices?
- there is increased back-pressure in the portal system
- this causes the vessels to become swollen / tortuous at the sites where the portal system anastomoses with the systemic venous system
- varices are swollen, tortuous vessels
At which sites do varices develop?
- gastro-oesophageal junction
- ileocaecal junction
- rectum
- anterior abdominal wall via the umbilical vein (caput medusae)
What are the symptoms associated with varices?
- varices do not produce symptoms until they start bleeding
- there is a high blood flow through varices
- patients can exsanguinate (bleed out) very quicky
What are the 3 main options for the treatment of stable varices?
propanolol:
- acts as a non-selective beta blocker to reduce portal HTN
elastic band ligation
injection of sclerosant:
- less effective than band ligation
What is involved in the transjugular intra-hepatic portosystemic shunt (TIPS) procedure?
- a wire is inserted under XR guidance
- the wire passes through the jugular vein, down the vena cava and into the liver via the hepatic vein
- a connection is made between the hepatic vein and portal vein
- a stent is put into place
- this allows blood to flow directly from the portal vein into the hepatic vein to relieve the pressure in the portal system + varices
When is a TIPS procedure performed?
- if medical and endoscopic treatment of varices fails
OR
- there are bleeding varices that cannot be controlled in other ways
What are the 4 stages involved in resuscitation when there are bleeding oesophageal varices?
terlipressin:
* or other vasopressin analogue
- causes vasoconstriction and slows bleeding
correct coagulopathy:
- with vitamin K and FFP
broad spectrum abx:
- prophylactic abx reduces mortality
intubation / ICU:
- consider ICU as patients can become life-threateningly unwell
FFP = fresh frozen plasma which contains many clotting factors
What is required urgently when oesophageal varices are bleeding?
- following resuscitation, urgent endoscopy is required
- there may be injection of sclerosant into the varices to cause “inflammatory obliteration”
- or elastic band ligation of varices
What is done if endoscopy fails to control bleeding varices?
Sengstaken-Blakemore tube
- an inflatable tube inserted into the oesophagus to tamponade the bleeding varices
Why does ascites occur as a result of cirrhosis?
- increased pressure in the portal system causes fluid to leak out of the capillaries in the liver / bowel
- fluid enters the peritoneal cavity
How does ascites affect the kidneys?
- there is a drop in circulating volume as fluid is lost into the peritoneal space
- kidneys secrete renin as a result of lower BP
- renin leads to increased aldosterone secretion
- there is increased reabsorption of fluid + sodium in the kidneys
What type of ascites is caused by cirrhosis?
transudative ascites
i.e. low protein content
What is involved in the management of ascites?
- low sodium diet
- anti-aldosterone diuretics (spironolactone)
- paracentesis (ascitic tap / drain)
- consider TIPS procedure / transplantation in refractory ascites
- prophylactic antibiotics
Why are prophylactic antibiotics given in ascites?
What antibiotics are given?
- to reduce the risk of spontaneous bacterial peritonitis (SBP)
- ciprofloxacin or norfloxacin are given
- given to all patients with < 15g/L protein in the ascitic fluid
When does ascites become clinically detectable?
it is not detectable until there is at least 500ml fluid present
What are the clinical features of ascites?
- abdominal distension / discomfort
- weight gain
- reduced appetite
- shortness of breath (due to diaphragmatic splinting in large volume ascites)
How is a sample of ascitic fluid obtained?
What colour would this be in cirrhosis?
- a sample is obtained using a neddle and syringe
- this is called “ascitic tap” or “paracentesis”
- fluid is clear / straw coloured in cirrhosis
What is spontaneous bacterial peritonitis (SBP)?
an infection developing in the ascitic fluid + peritoneal lining without any clear cause
(e.g. not secondary to ascitic drain / bowel perforation)
occurs in around 10% of patients with ascites secondary to cirrhosis
How does SBP present?
- it can be asymptomatic
- fever
- abdominal pain
- deranged bloods (raised WCC, CRP, creatinine / metabolic acidosis)
- ileus
- hypotension
as it can be asymptomatic, there should be a low threshold for ascitic fluid culture
What are the most common causative organisms of SBP?
- Escherichia coli
- Klebsiella pneumoniae
- Gram positive cocci (staphylococcus / enterococcus)
What is involved in the management of SBP?
- take an ascitic culture prior to giving antibiotics
- usually treated with IV cephalosporin - e.g. cefotaxime
What is hepatorenal syndrome and why does it occur?
- hypertension in the portal system leads to dilation of portal blood vessels
- blood pools in the portal vessels
- there is a loss of blood volume in other areas of circulation
- there is activation of the RAAS due to reduced kidney BP
- this results in renal vasoconstriction
- renal vasoconstriction and low circulatory volume starves the kidneys of blood
- there is rapidly deteriorating kidney function
What is the treatment for hepatorenal syndrome?
liver transplant
hepatorenal syndrome is fatal within 1 week if transplant is not performed
What causes hepatic encephalopathy?
- a build up of toxins in the blood - particularly ammonia
- ammonia is produced by intestinal bacteria when they break down proteins and is absorbed in the gut
Why does ammonia build up in the blood in cirrhosis?
- functional impairment of hepatocytes prevents metabolism of ammonia into harmless waste products
- collateral vessels between the portal / systemic circulation means ammonia can bypass the liver and directly enter the systemic circulation
How does hepatic encephalopathy present?
acute presentation:
- reduced consciousness
- confusion
chronic presentation:
- changes to personality / mood
- memory disturbances
What are the precipitating factors for hepatic encephalopathy?
- constipation
- electrolyte disturbances
- infection
- GI bleeding
- high protein diet
- medications (sedatives)
