Liver Cirrhosis Flashcards
What is Liver Cirrhosis?
Result of chronic inflammation
Cells replaced with scar tissue (fibrosis) and nodules of scar tissue
Most common causes of liver cirrhosis (4)
Alcoholic liver disease
Non Alcoholic Fatty Liver Disease
Hepatitis B
Hepatitis C
Rarer causes of liver cirrhosis (7)
Autoimmune hepatitis Primary biliary cirrhosis Haemochromatosis Wilsons Disease Alpha-1 antitrypsin deficiency Cystic fibrosis Drugs (e.g. amiodarone, methotrexate, sodium valproate)
Signs of cirrhosis (10)
Jaundice (raised bilirubin)
Hepatomegaly (can eventually shrink)
Splenomegaly (portal hypertension)
Spider Naevi
Palmar Erythema (hyperdynamic cirulation)
Gynaecomastia and testicular atrophy in males due to endocrine dysfunction
Bruising (abnormal clotting)
Ascites
Caput Medusae (portal hypertension)
Asterixis – “flapping tremor” in decompensated liver disease
Expected blood results (6)
Liver biochemistry - often normal (decompensated cirrhosis ALT, AST, ALP, bilirubin deranged)
Albumin level drops and the prothrombin time increases as the synthetic function becomes worse
Hyponatraemia =fluid retention
Urea and cr deranged in hepatorenal syndrome
Viral markers and autoantibodies can help est. cause
Alpha-fetoprotein tumour marker for hepatocellular carcinoma (6 monthly)
What is found on 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
What does a fibroscan do?
FibroScan” can be used to check the elasticity of the liver
Helps assess the degree of cirrhosis.
NICE recommend retesting every 2 years in patients at risk of cirrhosis:
Hepatitis C
Heavy alcohol drinkers (men drinking > 50 units or women drinking > 35 units per week)
Diagnosed alcoholic liver disease
Non alcoholic fatty liver disease and evidence of fibrosis on the ELF blood test
Chronic hepatitis B (yearly)
Why is endoscopy used to assess for in liver cirrhosis?
Assess for and treat oesophageal varices when portal hypertension is suspected
What is the Child-Pugh score?
Indicates severity of liver cirrhosis based on: Bilirubin Albumin INR Ascites Encephalopathy
What is the MELD score?
Recommended by NICE to be used every 6 months in patients with compensated cirrhosis
Bilirubin, creatinine, INR and sodium and whether they are requiring dialysis
Gives a percentage estimated 3 month mortality and helps guide referral for liver transplant
General management of liver 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
Manage complications
Complications of liver cirrhosis
Malnutrition
Portal Hypertension, Varices and Variceal Bleeding
Ascites and Spontaneous Bacterial Peritonitis (SBP)
Hepato-renal Syndrome
Hepatic Encephalopathy
Hepatocellular Carcinoma
Where do varices occur?
Where the portal system anastomoses with the systemic venous system
Gastro oesophageal junction
Ileocaecal junction
Rectum
Anterior abdominal wall via the umbilical vein (caput medusae)
What is the treatment for stable varices?
Propranolol reduces portal hypertension by acting as a non-selective beta blocker
Elastic band ligation of varices
Injection of sclerosant (less effective than band ligation)
Transjugular Intra-hepatic Portosystemic Shunt (TIPS)
What is the treatment for bleeding oesophageal varices?
Terlipressin (vasopressin analogue) causes vasoconstriction - slows bleeding
Correct any coagulopathy
broad spectrum antibiotics prophylactic
Consider ICU/intubation
Urgent endoscopy
Sclerosant used to cause “inflammatory obliteration” of the vessel
Elastic band ligation of varices
What is used in treating oesophageal varices if endoscopy fails?
Sengstaken-Blakemore Tube is an inflatable tube inserted into the oesophagus to tamponade the bleeding varices
What is the management of ascites/
Low sodium diet
Anti-aldosterone diuretics (spironolactone)
Paracentesis (ascitic tap or ascitic drain)
Prophylactic antibiotics against spontaneous bacterial peritonitis (ciprofloxacin or norfloxacin) in patients with less than 15g/litre of protein in the ascitic fluid
Consider TIPS in refractory ascites
Consider transplantation in refractory ascites
What is spontaneous bacterial peritonitis? (SBP)
Infection developing in the ascitic fluid and peritoneal lining without any clear cause
Occurs in around 10% of patients with ascites secondary to cirrhosis
Mortality of 10-20%
Presentation of SBP?
Can be asymptomatic so have a low threshold for ascitic fluid culture
Fever
Abdominal pain
Deranged bloods (raised WBC, CRP, creatinine or metabolic acidosis)
Ileus
Hypotension
Most common organisms causing SBP
Escherichia coli
Klebsiella pnuemoniae
Gram positive cocci (such as staphylococcus and enterococcus)
Management of SBP
Take an ascitic culture prior to giving antibiotics
Usually treated with an IV cephalosporin such as cefotaxime
What is hepatorenal syndrome?
Hypertension in the portal system leads to dilation of the portal blood vessels due to blood pooling
Loss of blood volume in other areas of the circulation, including the kidneys
Leads to hypotension in the kidney and activation of the renin-angiotensin system
Leads to vasoconstriction, which combined with low circulation volume leads to starvation of blood to the kidney
Rapid deterioration of kidey function - fatal within a week without transplant
What is hepatic encephalopathy?
AKA portosystemic encephalopathy
Caused by build-up of toxins in the brain inc. AMMONIA ( produced by intestinal bacteria when they break down proteins and is absorbed in the gut)
Functional impairment of the liver cells prevents them metabolising the ammonia into harmless waste products
Collateral vessels between the portal and systemic circulation mean that the ammonia bypasses liver altogether and enters the systemic system directly
How does hepatic encepahlopathy present?
Acutely, it presents with reduced consciousness and confusion
Chronically with changes to personality, memory and mood
What are the precipitating factors to hepatic encephalopathy? (6)
Constipation Electrolyte disturbance Infection GI bleed High protein diet Medications (particularly sedative medications)
What is the management of hepatic encephalopathy?
Laxatives (i.e. lactulose) promote the excretion of ammonia. The aim is 2-3 soft motions daily. They may require enemas initially
Antibiotics (i.e. rifaximin) reduces the number of intestinal bacteria producing ammonia
Rifaximin is useful as it is poorly absorbed and so stays in the GI tract
Nutritional support - May need nasogastric feeding.
