Cirrosis hepatis

Nugroho BS.
• Sirosis adalah suatu keadaan patologis yang
menggambarkan stadium akhir fibrosis hepatik yang
berlangsung progresif yang ditandai dengan distorsi
dari arsitektur hepar dan pembentukan nodulus
regeneratif. Gambaran ini terjadi akibat adanya
nekrosis hepatoselular
• The liver weighs about 3 pounds and is the largest solid organ in the body.
It performs many important functions, such as:
• Manufacturing blood proteins that aid in clotting, oxygen transport, and
immune system function
• Storing excess nutrients and returning some of the nutrients to the
bloodstream
• Manufacturing bile, a substance needed to help digest food
• Helping the body store sugar (glucose) in the form of glycogen
• Ridding the body of harmful substances in the bloodstream, including
drugs and alcohol
• Breaking down saturated fat and producing cholesterol
• Sirosis hati mengakibatkan terjadinya 35.000 kematian setiap tahunnya di
Amerika . Di Indonesia data prevalensi sirosis hepatis belum ada. Di RS
Sardjito Yogyakarta jumlah pasien sirosis hepatis berkisar 4,1% dari pasien
yang dirawat di Bagian Penyakit Dalam dalam kurun waktu 1 tahun (data
tahun 2004). Lebih dari 40% pasien sirosis adalah asimptomatis
sering tanpa gejala sehingga kadang ditemukan pada waktu pasien me
lakukan pemeriksaan rutin atau karena penyakit yang lain
 What Causes Cirrhosis of the Liver?
• Hepatitis C, fatty liver, and alcohol abuse are the most common causes of cirrhosis of the liver in
the U.S., but anything that damages the liver can cause cirrhosis, including:
• Fatty liver associated with obesity and diabetes
• Chronic viral infections of the liver (hepatitis types B, C, and D; Hepatitis D is extremely rare)
• Blockage of the bile duct, which carries bile formed in the liver to the intestines, where it helps in
the digestion of fats; in babies, this can be caused by biliary atresia in which bile ducts are absent or
damaged, causing bile to back up in the liver. In adults, bile ducts may become inflamed, blocked,
or scarred, due to another liver disease called primary biliary cirrhosis.
• Repeated bouts of heart failure with fluid backing up into the liver
• Certain inherited diseases such as:
– Cystic fibrosis
– Glycogen storage diseases, in which the body is unable to process glycogen, a form of sugar that is
converted to glucose and serves as a source of energy for the body
– Alpha 1 antitrypsin deficiency, an absence of a specific enzyme in the liver
– Diseases caused by abnormal liver function, such as hemochromatosis, a condition in which excessive iron is
absorbed and deposited into the liver and other organs, and Wilson's disease, caused by the abnormal
storage of copper in the liver
 GEJALA KLINIS:
• GEJALA KLINIS:
Dibagi dua stadium :
• Sirosis kompensata dengan gejala klinis yang
belum tampak
• Sirosis dekompensata dengan gejala klinis
yang jelas
Pada saat ini skor METAVIR direkomendasikan untuk menilai fibrosis hati
(Tabel) Skoring METAVIR pada fibrosis hati(Sebastiani, 2006)
____________________________________________________
Stage Gambaran
____________________________________________________
F0 Tanpa fibrosis
F1 Fibrosis portal tanpa fibrosis septa
F2 Fibrosis portal dengan sedikit fibrosis septa
F3 Fibrosis septal tanpa sirosis
F4 Sirosis
____________________________________________________
• Assessing degree of liver fibrosis and cirrhosis

In resource-limited settings, it is suggested that the

aminotransferase/platelet ratio index (APRI) or FIB4 tests be
used for the assessment of hepatic fibrosis rather than other
non-invasive tests that require more resources such as
elastography or Fibrotest (conditional recommendation, low
quality of evidence).
• Noninvasive markers of fibrosis
The noninvasive markers used to assess fibrosis were the AST/ALT ratio
(AAR), APRI score, BARD score, FIB-4 score, and NAFLD fibrosis score (NFS).
These were calculated using the following equations:
• Cirrhosis has many causes. It can result from direct injury to the liver cells (such as from
hepatitis) or from indirect injury via inflammation or obstruction of bile ducts
,which drain the liver cells of bile.
• Common causes of direct liver injury include:
Chronic alcoholism (most common cause in the U.S.).
Chronic viral hepatitis (types B, C and D).
Autoimmune hepatitis.
• Common causes of indirect injury by way of bile duct damage include ,
Primarybiliarycirrhosis : the liver’s bile ducts are slowly destroyed.
Primarysclerosingcholangitis : bile ducts inside and outside the liver become inflamed and
scarred.
Biliaryatresia : injury and loss (atresia) of the bile ducts that are responsible for draining bile
from the liver; affects newborn infants.
• Less common causes of cirrhosis include direct liver injury from inherited disease such as
cystic fibrosis, alpha-1-antitrypsin deficiency, galactosemia and glycogen storage disease.
• Two inherited disorders result in the abnormal storage of metals in the liver leading to tissue
damage and cirrhosis:

Wilson’sdisease: Patients store too much copper in the liver, brain, kidneys and corneas of
the eyes.
• Hemochromatosis : Too much iron is absorbed and the excess iron is deposited in the liver
and other organs, such as the pancreas, skin, intestinal lining, heart and endocrine glands.
• Very rare causes of cirrhosis include reactions to drugs (e.g.,
vitamin A, Dilantin, methotrexate, amiodarone), exposure to
environmental toxins, and repeated bouts of heart failure
with liver congestion.
• If the cause of cirrhosis is still not clear after a full evaluation,
it is termed “ cryptogeniccirrhosis .” As many as 10 percent of
patients with cirrhosis fall into this category
• Serum marker dapat digunakan untuk fibrosis hati.Serum marker untuk fibrosis hati dibagi atas 2 kelompok yaitu petanda
langsung dan tidak langsung.

A. Petanda tidak langsung

Studi studi sebelumnya telah mengevaluasi petanda non invasive
untuk memprediksi keberadaan fibrosis atau sirosis pada penderita
hepatitis kronis, seperti :
1. Rasio AST/ALT ( indeks AAR: Rasio AST/ALT lebih besar dari 1
dengan kuat menyarankan sirosis dengan sensitivitas 78% dan
spesifisitas 97%
2. Skor PGA: Kombinasi pengukuran indeks protombin, GGT dan
apolipoprotein A1 (PGA).
3. Fibrotest, pemeriksaan melibatkan alfa-2 makroglobulin, alfa2
globulin, gamma globulin, apolipoprotein A1, gamma GT, dan
bilirubin total.
4. Acti Test, pemeriksaan memodifikasi Fibrotest dengan menyertakan
ALT
5. Skor Forns ( indeks Forns), berdasarkan 4 variabel umum dijumpai di
kloinik meliputi jumlah trombosit, umur, level kolesterol, dan GGT.
6. Rasio AST/trombosit (indeks APRI), model ini konsisten dan objektif
pada laboratorium rutin pasien pasien dengan hati kronis.
7. Fibroindex menggunakan variable trombosit, AST dan YGlobulin.
8. Kombinasi AST,INR, trombosit( indeks GUCI)

B.Penanda langsung (direct marker)

Penanda langsung seperti : Collagen type IV, Hyaluronic acid,
Procollagen III peptide, Platelet.
• METAVIR yang diajukan oleh Poynard dkk, yang terdiri dari 5 stage yaitu :

• FO ( tanpa fibrosis )
• F1 (Fibrosis ringan), ekspansi fibrosis sekitar zona portal atau vena sentral
• F2 (Fibrosis moderat), septa yang meluas sampai ke lobulus hati
• F3 (Fibrosis moderat) disertai bridging fibrosis (portal portal, sentral - sentra,portal sentral.
• F4 (Sirosis) nodulasi parenkimal dikelilingi septa fibrotik dan kerusakan arsitektur hati.

Derajat fibrosis hati berdasarkan

hasil FibroScan di bagi atas :

F0; Normal (<5 kPa),

F1; Mild (5,1 – 9 kPa),
F2;Moderate (9,1– 11 kPa),
F3; Severe (11,1 – 14,5),
F4; Sirosis (> 14,5 kPa ).