Liver Cirrhosis Flashcards
What is happens in liver cirrhosis?
Liver cirrhosis is the result of chronic inflammation and damage to liver cells.
When the liver cells are damaged they are replaced with scar tissue (fibrosis) and nodules of scar tissue form within the liver.
This fibrosis affects the structure and blood flow through the liver, which causes increased resistance in the vessels leading in to the liver. This is called portal hypertension.
Most common causes of cirrhosis (4)
Name some rarer causes
Alcoholic liver disease
Non Alcoholic Fatty Liver Disease
Hepatitis B
Hepatitis C
RARER: Autoimmune hepatitis Primary biliary cirrhosis Haemochromatosis Wilsons Disease Alpha-1 antitrypsin deficiency Cystic fibrosis Drugs (e.g. amiodarone, methotrexate, sodium valproate)
Examination findings in cirrhosis
Jaundice – caused by raised bilirubin
Hepatomegaly – however the liver can shrink as it becomes more cirrhotic
Splenomegaly – due to portal hypertension
Spider Naevi – these are telangiectasia with a central arteriole and small vessels radiating away
Palmar Erythema – caused by hyperdynamic circulation
Dupuntrye’s contracture
Gynaecomastia and testicular atrophy in males due to endocrine dysfunction
Bruising – due to abnormal clotting
Ascites
Caput Medusae – distended paraumbilical veins due to portal hypertension
Asterixis – “flapping tremor” in decompensated liver disease
Blood investigations in liver cirrhosis
Bloods:
- Liver biochemistry is often normal, however in decompensated cirrhosis all of the markers (ALT, AST, ALP and bilirubin) become deranged and Low Albumin
- Clotting screen: increased prothrombin time
- Urea and creatinine become deranged in hepatorenal syndrome + hyponatraemia indicates fluid retention in severe liver disease.
- Further bloods can help establish the cause of the cirrhosis if unknown (such as viral markers and autoantibodies).
- Alpha-fetoprotein is a tumour marker for hepatocellular carcinoma and can be checked every 6 months as a screening test in patients with cirrhosis along with ultrasound.
Other investigations in liver cirrhosis
Ultrasound
- Nodularity of the surface of the liver
- A “corkscrew” appearance to the arteries with increased flow as they compensate for reduced portal flow
- Enlarged portal vein with reduced flow
- Ascites
- Splenomegaly
- Ultrasound is also used as a screening tool for hepatocellular carcinoma. NICE recommend screening patients with cirrhosis for HCC every 6 months.
FibroScan
- “FibroScan” can be used to check the elasticity of the liver by sending high frequency sound waves into the liver. It helps assess the degree of cirrhosis.
Endoscopy
- Endoscopy can be used to assess for and treat oesophageal varices when portal hypertension is suspected.
CT and MRI scans
- CT and MRI can be used to look for hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes and ascites.
Liver Biopsy
- Liver biopsy can be used to confirm the diagnosis of cirrhosis.
What is a way of classifying the severity of cirrhosis?
Child-Pugh Score for Cirrhosis score indicates the severity of the cirrhosis and the prognosis (include the risk of varices)
Parameters include: [PAABE] Prothrombin time Albumin Ascites Bilirubin Encephalopathy
General Management for cirrhosis
Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
Endoscopy every 3 years in patients without known varices
High protein, low sodium diet
MELD score every 6 months
Consideration of a liver transplant
Managing complications as below
Complications of Cirrhosis
Malnutrition
Portal Hypertension, Varices and Variceal Bleeding
Ascites and Spontaneous Bacterial Peritonitis (SBP)
Hepato-renal Syndrome
Hepatic Encephalopathy
Hepatocellular Carcinoma
Hypoglycaemia of chronic liver disease
Prophylactic and Acute Management of Variceal Bleeding
Prophylaxis: Beta blocker
Acute:
- Terlipressin
- Vitamin K, Fresh frozen plasma, Packed red blood cells (G+S, cross match)
- Endoscopic Band Ligation
Ascites Management
Treat underlying Cause
MEDICAL
Spirinolactone
If this is not sufficient: therapeutic paracentesis
Contraindication to paracentesis (ascitic tap) in ascites management
Disseminated Intravascular coagulation (features: low fibrinogen, bleeding gums)
Acute abdomen requiring surgery
King’s College Hospital criteria for non-paracetamol liver failure for liver transplant
Prothrombin time >100s OR Any three of: Drug-induced liver failure Age under 10 or over 40 years 1 week from 1st jaundice to encephalopathy Prothrombin time >50s Bilirubin ≥300µmol/L.
