Liver Cirrhosis

Question 1

What is liver cirrhosis?

Answer 1

Liver cirrhosis is the result of chronic inflammation and damage to liver cells. The functional liver cells are replaced with scar tissue (fibrosis). Nodules of scar tissue form within the liver.

Question 2

How does liver cirrhosis lead to portal hypertension?

Answer 2

Fibrosis affects the structure and blood flow through the liver, increasing the resistance in the vessels leading into the liver.
This increases the resistance and pressure in the portal system

Question 3

What are the 4 most common causes of liver cirrhosis?

Answer 3

• Alcohol-related liver disease
• Non-alcoholic fatty liver disease (NAFLD)
• Hepatitis B
• Hepatitis C

Question 4

What are the rarer causes of liver cirrhosis?(7)

Answer 4

○ Autoimmune hepatitis
○ Primary biliary cirrhosis
○ Haemochromatosis
○ Wilsons disease
○ Alpha-1 antitrypsin deficiency
○ Cystic fibrosis
○ Drugs (e.g., amiodarone, methotrexate and sodium valproate)

Question 5

What are the signs of liver cirrhosis? (14)

Answer 5

Cachexia
Jaundice
Hepatomegaly
Small modular liver
Splenomegaly
Spider naevi
Palmar erythema
Gynaecomastia
Bruising
Excoriations
Ascites
Caput Madusae
Leukonykia
Asterixis

Question 6

What’s included in a non-invasive liver screen?

Answer 6

• Ultrasound liver (used to diagnose fatty liver)
• Hepatitis B and C serology
• Autoantibodies (autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis)
• Immunoglobulins (autoimmune hepatitis and primary biliary cirrhosis)
• Caeruloplasmin (Wilsons disease)
• Alpha-1 antitrypsin levels (alpha-1 antitrypsin deficiency)
• Ferritin and transferrin saturation (hereditary haemochromatosis)

Question 7

What is the first line test for assessing fibrosis in NAFLD?

Answer 7

Enhanced liver fibrosis (ELF) blood test

Question 8

What level indicated advanced fibrosis in an ELF blood test?

Answer 8

10.51 or above

Question 9

What is the MELD score?

Answer 9

Gives an estimated 3-month mortality in patients with cirrhosis to help guide referral for liver transplant
Done every 6 months

Question 10

What score gives and estimated 3 month mortality percentage in patients with cirrhosis?

Answer 10

MELD score

Question 11

What is the child-Pugh score?

Answer 11

Uses 5 factors to assess the severity of cirrhosis and prognosis

Question 12

What score assesses for severity and prognosis in cirrhosis?

Answer 12

Child-Pugh score

Question 13

What are the features of the child-Pugh score? (5)

Answer 13

• A – Albumin
• B – Bilirubin
• C – Clotting (INR)
• D – Dilation (ascites)
• E – Encephalopathy

Question 14

How does the child-Pugh score work?

Answer 14

Each factor is considered and scored 1, 2 or 3. The minimum overall score is 5 (scoring 1 for each factor), and the maximum is 15 (scoring 3 for each factor).

Question 15

What are the complications of liver cirrhosis? (6)

Answer 15

• Malnutrition and muscle wasting
• Portal hypertension, oesophageal varices and bleeding varices
• Ascites and spontaneous bacterial peritonitis
• Hepatorenal syndrome
• Hepatic encephalopathy
• Hepatocellular carcinoma

Question 16

How does cirrhosis cause malnutrition?

Answer 16

Loss of appetite

Cirrhosis affects protein metabolism in the liver and reduces the amount of protein the liver produces

disrupts the ability of the liver to store glucose as glycogen and release it when required

Question 17

What nutritional advise is given to patients with liver cirrhosis? (4)

Answer 17

• Regular meals
• High protein and calorie intake
• Reduced sodium intake to minimise fluid retention
• Avoiding alcohol

Question 18

What 2 veins join to form the portal vein?

Answer 18

Superior mesenteric
Splenic

Question 19

Where does the portal vein deliver blood to?

Answer 19

Liver

Question 20

What causes splenomegaly in liver cirrhosis?

Answer 20

Portal hypertension causes back pressure of blood into the spleen

Question 21

What is the prophylaxis of bleeding in stable oesophageal varices? (2)

Answer 21

Propranolol - decreases resistance and pressure
Variceal band ligation if beta blockers are contraindicated

Question 22

What type of fluid is found in ascites?

Answer 22

Transudative (low protein contents)

Question 23

How does ascites cause further fluid and sodium retention?

Answer 23

Ascites causes drop in circulating fluid
Reduced blood pressure to kidneys
This causes release of renin
This increases aldosterone secretion
This increases reabsorption of fluid and sodium in the kidneys

Question 24

What are the management options for ascites caused by cirrhosis? (6)

Answer 24

• Low sodium diet
• Aldosterone antagonists (e.g., spironolactone)
• Paracentesis (ascitic tap or ascitic drain)
• Prophylactic antibiotics (ciprofloxacin or norfloxacin) when there is <15 g/litre of protein in the ascitic fluid
• Transjugular intrahepatic portosystemic shunt (TIPS) is considered in refractory ascites
• Liver transplantation is considered in refractory ascites

Question 25

What is seen on an ultrasound in liver cirrhosis? (5)

Answer 25

• Nodularity of the surface of the liver
• A “corkscrew” appearance to the hepatic arteries with increased flow as they compensate for reduced portal flow
• Enlarged portal vein with reduced flow
• Ascites
• Splenomegaly

Question 26

What is transient elastograohy used for?

Answer 26

Aka fibroscan
Used to determine the degree of fibrosis
Used every 2 years in patients at risk of cirrhosis

Question 27

Which patients are at risk of cirrhosis and therefore recieve transient elastography every 2 years? (5)

Answer 27

• Alcohol-related liver disease
• Heavy alcohol drinkers (men drinking more than 50 units or women drinking more than 35 units per week)
• Non-alcoholic fatty liver disease and advanced liver fibrosis (score 10.51 or more on the ELF blood test)
• Hepatitis C
• Chronic hepatitis B - yearly screening

Question 28

What are the 4 principals of management of cirrhosis?

Answer 28

• Treating the underlying cause
• Monitoring for complications
• Managing complications
Liver transplant

Question 29

How are complications monitored in liver cirrhosis? (3)

Answer 29

• MELD score every 6 months
• Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
• Endoscopy every 3 years for oesophageal varices

Question 30

What are the 4 features of decompensated liver disease?

Answer 30

• A – Ascites
• H – Hepatic encephalopathy
• O – Oesophageal varices bleeding
• Y – Yellow (jaundice)

Question 31

When is liver transplant considered in liver cirrhosis?

Answer 31

When there are features of decompensated liver disease