Cirrhosis

Related Subjects: | Chronic liver disease | Cirrhosis | Alkaline phosphatase (ALP) | Liver Function Tests | Ascites Assessment and Management | Budd-Chiari syndrome | Autoimmune Hepatitis | Primary Biliary Cirrhosis | Primary Sclerosing Cholangitis | Wilson disease | Hereditary Haemochromatosis | Alpha-1 Antitrypsin (AAT) deficiency | Non alcoholic steatohepatitis (NASH) | Spontaneous Bacterial Peritonitis | Alcoholism and Alcoholic Liver Disease

Fibrosis & nodular regeneration resulting from hepatocellular injury. Major etiologies include viral hepatitis (esp HCV), alcoholism, nonalcoholic steatohepatitis

About

• Cirrhosis is defined as the presence of fibrous bands that divide the liver into regenerative nodules.
• Cirrhosis represents a late stage of progressive hepatic fibrosis
• It is a histological diagnosis and can be classified into micro and macronodular by the size of mm.
• Risk of developing Hepatocellular Carcinoma (Detected by USS and elevated Alpha-fetoprotein)
• Generally considered to be irreversible in its advanced stages.

Macronodular > 3 mm

• Chronic Viral Infection - HBV HCV
• Wilson's disease
• a-1 antitrypsin deficiency

Micronodular < 3 mm

• Alcohol
• Haemochromatosis
• NASH

Alcohol and liver

• Steatosis - is reversible with alcohol abstention
• Alcoholic hepatitis - Mallory body
• Alcoholic cirrhosis - hobnail appearance

Causes

• Chronic Hepatitis C infection (anti-HCV and HCV RNA)
• Alcoholic liver disease (AST>ALT Elevated GGT)
• Chronic Hepatitis B infection (HBsAg HBeAg/HBV-DNA)
• Autoimmune liver disease (Raised Ig and Autoantibodies)
• Primary Sclerosing cholangitis (pANCA MRCP/ERCP)
• Primary Biliary cirrhosis (Anti Mitochondrial Ab)
• Hereditary Haemochromatosis (Ferritin high Transferrin saturation high, Genetics)
• Wilson's disease (Young, low Ceruloplasmin raised Urine copper, KF rings)
• Budd-Chiari syndrome (USS caudate lobe)
• Drugs - Amiodarone, methotrexate, methyldopa
• Cystic fibrosis (genetics + sweat Cl)
• Alpha-1 antitrypsin (Young emphysema low serum AAT)
• Idiopathic - unknown

Drugs that should be avoided in Cirrhosis

• These would include NSAIDs with their effects on kidneys and gastric mucosa.
• ACE inhibitors may be involved in hepatorenal syndrome and are best stopped.
• Codeine, Narcotics, Benzodiazepines and anxiolytics can all precipitate or worsen hepatic encephalopathy

Complications

• Portal hypertension
• Liver failure
• Portosystemic Encephalopathy - always look for the flap and assess the mental state
• Variceal Bleeding formed from left gastric and short gastric veins to the oesophagus
• Ascites
• Spontaneous bacterial peritonitis
• Hepatorenal syndrome
• Osteoporosis
• Hepatocellular carcinoma

Investigations

• U&E LFT's (low Na common)
• Prothrombin time and Albumin reflect the liver synthetic function
• See above
• Alpha fetoprotein suggests Hepatocellular carcinoma
• Liver USS

Prognosis may be estimated through the Child-Pugh score

A = 5-6 points B = 7-9 points C = 10-15 points

In Primary Biliary Cirrhosis or Sclerosing cholangitis a higher range for bilirubin is used

MELD score

• Model for end stage liver failure
• 3.8 x Bilirubin (mg/dl) + 11.2 x INR + 9.6 x Creatinine + 6.4
• Online calculator which will give 1 year survival