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Clinical Skills Blogspot

Cirrhosis of the Liver

Title               

Ñ    Cirrhosis of the Liver

Definition

Cirrhosis of the liver refers to:

Ñ    Scarring of the liver

With:

Ñ    Diffuse fibrosis

Ñ    Regenerative parenchymal nodules

Ñ    Disturbed intrahepatic circulation

Caused by:

Ñ    Long standing, widespread, patchy hepatocellular necrosis

Pathogenesis

Causes

Biliary Tract Disorders

Ñ    Primary sclerosing cholangitis

Ñ    Secondary sclerosing cholangitis

Ñ    Primary biliary cirrhosis (PBC)

Hepatocellular disorders

Biological Agents

Viruses

Ñ    Hepatitis B

Ñ    Hepatitis C

Immune reactions

Ñ    Autoimmune hepatitis

Chemical Agents

Metabolic disorders

Ñ    Haemachromatosis

Ñ    Alpha ₁ antitrypsin deficiency

Ñ    Wilson’s disease

Ñ    Non-alcoholic fatty liver disease

Toxins

Ñ    Alcohol

Drugs

Ñ    Methotrexate

Ñ    Amiodarone

Vascular Disorders

Venous disease

Ñ    Budd-Chiari syndrome

Ñ    Tricuspid regurgitation

Ñ    Congestive cardiac failure

Ñ    Right heart failure

Ñ    Restrictive cardiomyopathy

Ñ    Constrictive pericarditis

Ñ    Veno-occlusive disease:

Jamaican bush tea

Complication of chemotherapy

Telangiectasia

Ñ    Osler-Rendu-Weber syndrome

Pathological Process

Ñ    Widespread, prolonged, patchy necrosis

Ñ    Replacement of necrotic tissue by fibrosis and regeneration

Ñ    Disorganisation of hepatic architecture

Ñ    Disturbed hepatic microcirculation

Resulting in:

Ñ    Chronic hepatocellular failure

Ñ    Portal hypertension

Clinical Features

History

E&M

Ñ    Tiredness

Ñ    Weight loss

Ñ    Fever

IS

Ñ    Pruritus:

PBC

RS

Ñ    Dyspnoea

GIT

Ñ    Anorexia

Ñ    Nausea

Ñ    Abdominal discomfort

RAG

Ñ    Loss of libido

Ñ    Impotence

Ñ    Amenorrhoea

HS

Ñ    Spontaneous bleeding

Ñ    Easy bruising

CNS

Ñ    Depression

LMS

Ñ    Muscle cramps

Past Illnesses

Ñ    Hepatitis

Ñ    Jaundice

Drug History

Ñ    Blood transfusion

Ñ    Methotrexate

Ñ    Amiodarone

Personal History

Ñ    Alcohol abuse

Ñ    Drug abuse

Family History

Ñ    Liver disease

Examination

E&M

Ñ    Loss of weight

IS

Ñ    Jaundice

Ñ    Skin pigmentation

Ñ    Spider naevi

Ñ    Palmar erythema

Ñ    Cyanosis

Ñ    Clubbing

Ñ    Leuconychia

Ñ    Loss of body hair

Ñ    Excoriations

RS

Ñ    Foetor hepaticus

GIT

Ñ    Parotid swelling

Ñ    Venous collaterals:

Abdominal wall

Ñ    Hepatomegaly

Ñ    Splenomegaly

Ñ    Ascites

Ñ    Venous hum

RAG

Ñ    Gynaecomastia

Ñ    Testicular atrophy

HS

Ñ    Petechiae

CNS

Ñ    Flapping tremor

LMS

Ñ    Dupuytren’s contracture

Complications

RS

Ñ    Hepatopulmonary syndrome:

Caused by intrapulmonary arteriovenous dilatations:

·          Dyspnoea

·          Platypnoea

GIT

Ñ    Variceal haemorrhage

Ñ    Spontaneous bacterial peritonitis

Ñ    Hepatoma

Ñ    Nutritional failure

KUS

Ñ    Hepatorenal syndrome

CNS

Ñ    Portosystemic encephalopathy

LMS

Ñ    Osteoporosis

Investigations

Fluids

Blood

Haematology

Ñ    Anaemia:

Macrocytic or normocytic

Ñ    Neutropaenia:

Hypersplenism

Ñ    Thrombocytopaenia:

Hypersplenism

Biochemistry

Ñ    Alanine aminotransferase:

Normal or elevated

Ñ    Bilirubin:

Normal or elevated

Ñ    Alkaline phosphatase:

Normal or elevated

Ñ    Albumin:

Low

Ñ    Urea:

Low in decompensated cirrhosis

Ñ    Elevated urea:

Dehydration

Bleeding

Hepatorenal syndrome

Ñ    Hyponatraemia

Ñ    Hypomagnesaemia

Ascitic Fluid

Haematology

Ñ    Neutrophils > 250 /mm³:

Suggests spontaneous bacterial peritonitis

Imaging

Ultrasound

Evaluate:

Ñ    Size of liver

Ñ    Focal lesions

Ñ    Hepatic vein thrombosis

Ñ    Portal vein thrombosis

Ñ    Direction of blood flow in portal vein

Ñ    Ascites

Tissue Diagnosis

Liver Biopsy

Ñ    Shows the typical features of cirrhosis

Ñ    Cause may be determined

Management

Control

Drugs

Ñ    Interferon, ribavarin:

Hepatitis C

Ñ    Ursodexoycholic acid:

PBC

Ñ    Penicillamine:

Wilson’s disease

Biological Agents

Ñ    Venesction:

Haemachromatosis

Lifestyle Adjustments

Ñ    Abstinence from alcohol

Support

GIT

Variceal bleeding

Drugs

Ñ    Beta blockers:

Decrease portal pressure

Ñ    Terlipressin:

Decrease portal pressure

Ñ    Sucralfate:

Following variceal banding:

·          Reduce banding induced ulceration

Ñ    Ciprofloxacin:

Following banding:

·          Reduce sepsis

Surgery

Ñ    Banding of varices

Ñ    TIPSS:

Transjugular intrahepatic portosystemic shunt

GIT

Ascites

Drugs

Ñ    Spironolactone

Ñ    Furosemide

Ñ    Cephalosporin:

Treat spontaneous bacterial peritonitis (SBP)

Ñ    Norfloxacin:

Prevent SBP

Surgery

Ñ    Paracentesis abdominis:

Drain ascites

Ñ    TIPSS:

Resistant cases

Biological agents

Ñ    Salt free albumin infusion:

Correct hypoalbuminaemia

Lifestyle Adjustments

Ñ    Low salt diet

GIT

Nutritional failure

Lifestyle Adjustments

Ñ    Dietary supplementation

Equipment

Ñ    Nasogastric feeding:

If:

·          Drowsy due to encephalopathy

·          Extreme cachexia

CNS

Portosystemic encephalopathy

Drugs

Ñ    Lactulose

Ñ    Phosphate enemas

KUS

Hepatorenal syndrome

Drugs

Ñ    Terlipressin

Biological agents

Ñ    Salt free albumin infusion:

Correct hypoalbuminaemia

Equipment

Ñ    Haemodialysis

RS

Hepatopulmonary syndrome

Equipment

Ñ    Supplemental oxygen

Biological Agents

Ñ    Liver transplant

End Stage Liver Disease

Biological Agents

Ñ    Liver transplant

Ñ    Indications for liver transplant vary depending on the transplant unit concerned

Ñ    Timing of transplant is very difficult

Ñ    The factors taken into consideration when deciding on liver transplant are:

·          Debilitating symptoms

·          Ascites

·          Encephalopathy

·          Bilirubin

·          Albumin

·          Prothrombin time

In short, failure of the vital functions of the liver

Prevention

Ñ    Prevention of underlying diseases

Ñ    Review medications that precipitate hepatic encephalopathy and renal impairment:

Opiates

NSAIDs

Aminoglycosides

Statins

Prognosis

Ñ    Poor

Ñ    5 year mortality approximately 50 %

 

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