Liver Cirrhosis
Review Hepatology
What is Liver Cirrhosis?
Diffuse
fibrosis of the
liver with nodule
formation
Abnormal response of
the liver to any chronic
injury
Epidemiology
According to public government hospital
report in Indonesia, average prevalence of
liver cirrhosis is 3,5% of all Internal
medicine patients or 47,4% of all
hepatology patients
Prevalence ratio of liver cirrhosis in
male : female is 2,1 : 1 and average of
age is 44 years old
Causes of Cirrhosis
1.
Chronic viral hepatitis
2.
Metabolic: hemochromatosis, Wilson dis, alfa-1antitrypsin, NASH
3.
Prolonged cholestasis (primary biliary cirrhosis,
primary sclerosing cholangitis)
4.
Autoimmune diseases (autoimmune hepatitis)
5.
Drugs and toxins
6.
Alcohol
Pathophysiology
Irreversible chronic injury of
the hepatic parenchyma
Extensive fibrosis - distortion
of the hepatic architecture
Formation of regenerative
nodules
Mechanism of Portal HTN
Cirrhosis
Resistance
portal flow
Mechanical
Nodules
Dynamic
Nitric oxide
Clinical Manifestations
Spider angiomas
Palmar erythema
Nail changes
Muehrcke's nails
Terrys nails
Gynecomastia
Testicular atrophy
Clinical Manifestations
Muehrcke's
nails
Terrys nails
Clinical Manifestations
Fetor hepaticus
Jaundice
Asterixis
Pigment gallstones
Parotid gland
enlargement
Cruveilhier-Baumgarten
murmur
Hepatomegaly
Splenomegaly
Caput medusa
Laboratory Studies
most common measured laboratory test classified as
LFTs include
the enzyme tests (principally the serum
aminotransferases, alkaline phosphatase, and gamma
glutamyl transpeptidase), the serum bilirubin
tests of synthetic function (principally the serum albumin
concentration and prothrombin time)
Radiologic Modalities
Can occasionally suggest the presence of cirrhosis, they
are not adequately sensitive or specific for use as a
primary diagnostic modality
Major utility of radiography in the evaluation of the
cirrhotic patient is in its ability to detect complications
of cirrhosis
Fibroscan
Diagnosis
Liver biopsy
Obtained by either a percutaneous, transjugular,
laparoscopic, or radiographically-guided fine-needle
approach
Sensitivity of a liver biopsy for cirrhosis is in the range of
80 to 100 percent depending upon the method used, and
the size and number of specimens obtained
Diagnosis
not necessary if the clinical, laboratory, and radiologic
data strongly suggest the presence of cirrhosis
liver biopsy can reveal the underlying cause of cirrhosis
Liver Biopsy Cirrhosis
Morphologic Classification
Micronodular cirrhosis:
Morphologic Classification
Relatively nonspecific with regard to etiology
The morphologic appearance of the liver may
change as the liver disease progresses
micronodular cirrhosis usually progresses to
macronodular cirrhosis
Serological markers available today are more
specific than morphological appearance of the
liver for determining the etiology of cirrhosis
Accurate assessment of liver morphology may
only be achieved at surgery, laparoscopy, or
autopsy
Evaluation
of Cirrhosis
Compensated vs
Decompensated
Complications
Ascites
Spontaneous Bacterial Peritonitis
Hepatorenal syndrome
Variceal hemorrhage
Hepatopulmonary syndrome
Complications
Other Pulmonary syndromes
Hepatic hydrothorax
Portopulmonary HTN
Hepatic Encephalopathy
Hepatocellular carcinoma
Ascites
Accumulation of fluid within the peritoneal cavity
Most common complication of cirrhosis
Two-year survival of patients with ascites is
approximately 50 percent
Mechanism of Ascites
Ascites
Assessment of ascites
Grading
Grade
1 mild; Detectable only by ultrasound examination
Grade
2 moderate; Moderate symmetrical distension of
the abdomen
Grade
3 large or gross asites with marked abdominal
distension
Older system -subjective
1+
minimal, barely detectable
2+
moderate
3+
massive, not tense
4+massive
and tense
Ascites
Imaging studies for confirmation of ascites
Ultrasound is probably the most cost-effective modality
Ascites
Who gets a belly tap?
What do I want to order ?
Portal hypertension
or heart failure
Peritonial disease
or kidney disease
Ascites
Treatment aimed at the underlying cause of the hepatic
disease and at the ascitic fluid itself
Dietary sodium restriction
Limiting sodium intake to 88 meq (2000 mg) per day
Ascites
The most successful therapeutic regimen is the
combination of single morning oral doses of
Spironolactone and Furosemide, beginning with 100
mg and 40 mg
Two major concerns with diuretic therapy for cirrhotic
ascites:
Overly rapid removal of fluid
Progressive electrolyte imbalance
Spontaneous Bacterial
Peritonitis
Infection of ascitic fluid without evidence for an
intraabdominal secondary source such as a perforated
viscus
Almost always seen in the setting of end-stage liver
disease
The diagnosis is established by
A positive ascitic fluid bacterial culture
Elevated ascitic fluid absolute polymorphonuclear
leukocyte (PMN) count ( >250 cells/mm3)
Spontaneous Bacterial
Peritonitis
Clinical manifestations:
Fever
Abdominal pain
Abdominal tenderness
Altered mental status
Treatment
: third generation
cephalosporin IV
Hepatorenal syndrome
acute
renal failure coupled with
advanced hepatic disease (due to cirrhosis or
less often metastatic tumor or severe alcoholic
hepatitis)
characterized
by:
Oliguria
benign
very
urine sediment
low rate of sodium excretion
progressive
rise in the plasma creatinine
concentration
Hepatorenal Syndrome
Type
1 : rapidly progressive, high
mortality
Type 2: slower progression
R/O volume depletion secondary
to diuretics
IV vasoconstrictors
Liver transplantation
Variceal
hemorrhage
Varices
Esophagus
Gastric
Colo-rectal
Portal
hypertensive
gastropathy
Varices Diagnosis
History : Hematemases, melena
Physical examination
Ultrasound abdomen
Endoscopy
Varices Management-General
ABC
2 IV Lines
Type and cross match
Resuscitation
IVF
Blood
Platelet transfusion (platelet <75,000)
Fresh frozen plasma (Correct Pt)
Varices Management-Specific
IV vasoconstrictors (Octreotide)
Endoscopic therapy
Banding
Sclerotherapy
Shunting
Surgical
TIPS
Variceal Banding
Types of Shunts
Surgical shunt
TIPS (Transjugular intrahepatic
portosystemic shunt)
Varices - Prevention
Treat
underlying disease
Endoscopic banding protocol
B-blockers
Shunt surgery (only if no
cirrhosis)
Liver transplantation
Hepatopulmonary syndrome
Triad:
Liver disease
Increased alveolar-arterial gradient while breathing room
air
Evidence for intrapulmonary vascular abnormalities,
referred to as intrapulmonary vascular dilatations (IPVDs)
Hepatic Hydrothorax
Pleural
effusion in a patient with cirrhosis
and no evidence of underlying
cardiopulmonary disease
Movement
of ascitic fluid into the pleural
space through defects in the diaphragm,
and is usually right-sided
Diagnosis
reveals
serum
-pleural fluid analysis
a transudative fluid
to fluid albumin gradient greater than 1.1
Hepatic hydrothorax
Confirmatory study:
Scintigraphic studies demonstrate tracer in the chest
cavity after injection into the peritoneal cavity
Treatment options:
diuretic therapy
periodic thoracentesis
TIPS
Portopulmonary HTN
Refers to the presence of pulmonary hypertension in
the coexistent portal hypertension
Prevalence in cirrhotic patients is approximately 2
percent
Clinical manifestations:
fatigue, dyspnea, peripheral edema, chest pain, and
syncope
Diagnosis:
Suggested by echocardiography
Confirmed by right heart catheterization
Hepatic Encephalopathy
Spectrum of potentially reversible neuropsychiatric
abnormalities seen in patients with liver dysfunction
Diurnal sleep pattern pertubation
Asterixis
Hyperactive deep tendon reflexes
Transient decerebrate posturing
Flapping Tremor
Pathogenesis of Hepatic Encephalopathy
BRAIN
Porta systemic
shunts
LIVER
Toxic N2 metabolites
From Intestines
Hepatic Encephalopathy
Hepatic Encephalopathy
Monitoring for events likely to precipitate HE [i.E.-
variceal bleeding, infection (such as
SBP), the administration of
sedatives, hypokalemia, and
hyponatremia]
Reduction of ammoniagenic substrates
Lactulose / lactitol
Dietary restriction of protein
Zinc and melatonin
Hepatocellular Carcinoma
Patients with cirrhosis have a markedly increased risk of
developing hepatocellular carcinoma
Incidence in well compensated cirrhosis is
approximately 3 percent per year
Hepatocellular Carcinoma
Hepatocellular Carcinoma
Symptoms
are largely due to mass
effect from the tumor
Pain,
early satiety, obstructive jaundice,
and a palpable mass
Serum
AFP greater than 500
micrograms/l in a patient with
cirrhosis are virtually diagnostic
Median
survival following diagnosis is
approximately 6 to 20 months
Prognostic Tools
MELD (model for end-stage liver disease)
Identify patients whose predicted survival post-procedure
would be three months or less
MELD = 3.8[serum bilirubin (mg/dL)] +
11.2[INR] + 9.6[serum creatinine (mg/dL)]
+ 6.4
MELD Score
Prognostic Tools
Child-Turcotte-Pugh (CTP) score
initially designed to stratify the risk of portacaval shunt
surgery in cirrhotic patients
based upon five parameters: serum bilirubin, serum
albumin, prothrombin time, ascites and encephalopathy
good predictor of outcome in patients with complications
of portal hypertension
Prognostic Tools
APACHE III (acute physiology and chronic health evaluation system)
Designed to predict an individual's risk of dying in the hospital
Treatment Options
The major goals of treating the cirrhotic patient
include:
Slowing or reversing the progression of liver disease
Preventing superimposed insults to the liver
Preventing and treating the complications
Determining the appropriateness and optimal timing for
liver transplantation
Liver Transplantation
Liver transplantation is the definitive treatment for
patients with decompensated cirrhosis
Depends upon the severity of disease, quality of life
and the absence of contraindications
Liver Transplantation
Minimal criteria for listing cirrhotic patients on the
liver transplantation list include
A child-Pugh score 7
Less than 90 percent chance of surviving one year without
a transplant
An episode of gastrointestinal hemorrhage related to
portal hypertension
An episode of spontaneous bacterial peritonitis
Vaccinations
Hepatitis A and B
Pneumococcal vaccine
Influenza vaccination
Surveillance
Screening recommendations:
serum AFP determinations and ultrasonography every six
months
Avoidance of Superimposed
Insults
Avoidance of:
Alcohol
Acetaminophen
Herbal
medications
Thank You
