LIVER CIRRHOSIS

DR ALEX MOGERE
CONSULTANT PHYSICIAN
Question.
Cirrhosis of the liver

• Final common pathway for many hepatic

disorders
Chronic cellular distruction
Fibrosis
regenerative nodules
Distortion of architecture
portal hypertention
Defn.
• A diffuse process characterized by liver necrosis and fibrosis and
conversion of normal liver architecture into structurally abnormal
nodules that lack normal lobular organization(WHO)
Cirhosis of the liver cont…..

• Classification:
 micronodular (ETOH)
 Macronodular (viral)
Other Causes of cirrhosis cont…..

• Sarcoidosis
• Drugs (eg Methotrexate)
• Glycogen storage disorder
Primary biliary cirrhosis
• Strong female preponderance .
• Median age of around 50 years at the time of diagnosis.
• X-terized by portal inflammation and necrosis of cholangiocytes in small- and medium-
sized bile ducts.
• Antimitochondrial antibodies (AMA) are present in about 90% of patients with PBC.
• Most pts are asymptomatic at Dx.
• Cholestatic liver enzyme abnormalities with an elevation in GGT and ALP along with mild
elevations in aminotransferases (ALT and AST)
• Liver transplantation is the Tx of choice for pts with decompensated cirrhosis due to PBC
• UDCA is the only approved Tx that has some degree of efficacy by slowing the rate of
progression of the disease.
Pathology in liver cirrhosis
• Nodularity-regenerating nodules
• Fibrosis-deposition of dense fibrous septa
• Hepatocytes: abnormalities(pleomorphism, dysplasia, hyperplasia)
• Grossly: irregular surface, firm
Clinical presentation

• General decline in health.

• Non specific complaints
• Anorexia,weight loss, fatigue, malaise,weakness
• Advanced stages present with:
Complication of portal hypertension
Clinical Presentation Conti…..

• Endocrine:
Diabetes mellitus
Gynaecomastia
Palmar erythema
Pulmonary
Hypoxaemia, Pleural effusion, hepato pulmonary
syndrome
Cont. Clinical presentation ..

• Hemorrhagic tendency;
menorrhagia,purpura,epistaxis
• Renal
Renal failure 2nd degree
Hepato renal syndrome 1
Hepatic encephalopathy
Palmar erythema
Anemia in cirrhosis
Patients may be anemic either from:
• chronic GI blood loss,
• nutritional deficiencies, or
• hypersplenism related to portal hypertension, or
• as a direct suppressive effect of alcohol on the bone marrow.
• Zieve’s syndrome(unique hemolytic anemia)
Suspect liver cirrhosis if
Labs;
• Chronic abnormal amino transferases
• Low alb <3.8g/dl
• Prolonged prothrombin time ,INR> 1.3
• Raised bilirubin
• Portal htn- thrombocytopenia
• AST/ALT >1
p/e
• Small liver span
• Splenomegaly
• Palpable left lobe of liver
• Stigmata of CLD; palmar erythema, muscle wasting,etc
• Signs of decompensation; ascites, asterixis, JN
Diagnosis Of Liver cirrhosis

• Lab Tests:
LFTS -may be normal
Coagulation profile( INR, PTI, )
U/E/C
Albumin and serum protein
TBC:- platelet count, Anaemia
Viral Markers: HBV, HCV
ANA,
aSMA/AMA
Diagnosis of liver cirhosis

• Radiology:- U/S, CT scan , MRI, Doppler U/S,

ERCP/OGD
Diagnosis of liver cirrhosis conti…

• Liver biopsy
 gold standard: clue to underlying cause
 risk of bleeding
 Trans jugular approach
Complications of cirrhosis
Management

• Control of ascites
• Varices: beta blockers,banding,sclerotherapy
• Encephalopathy
• Screening for Hepatocellular carcinoma
• Liver Transplant
Cont.mx
• Wilson disease-penicillamine
• Hemochromatosis-phlebotomy
• Chronic viral hepatitis-antivirals
• Established cirrhosis-tx complications
• Maintenance of nutrition
• Liver transplantation
CONT. CHILD PUGH CLASSIFICATION

• One and two yr survival rates:

1 yr 2 yr
• Class A 100% 85%
• Class B 80% 60%
• Class C 45% 35%
Ascitis

• Defination: Pathological accumulation of fluid

within the peritoneal cavity
Causes of Ascitis:
• Chronic liver disease
• Peritoneal infections, Cirhosis, alcoholic hepatitis, carcinomatosis

• Heart failure
• Malignancy
Causes Of Ascitis conti….

• TB
• Fulminating Hepatic failure
• Pancreatitis
• Nephrogenous
• Billiary Ascitis
• Serositis
• MEIgs syndrome
Pathogenesis of Ascitis

• Portal Hypertension is prerequisite for ascites

formation in liver disease
• SAAG Raised >1.1gldl
• Peripheral arterial vasodilation theory
Clinical Presentation

• History helps evaluate cause of ascites

• Alcohol intake
• Hx of unprotected sex HBV, HCV
• Family Hx of wilsons, Hemachromatosis
Presentation symptoms and signs

• Jaundice, pedal edema

• G.I bleeding
• Encelephalopathy
• Wt loss – cancer
• Cardiomyopathy-Heart Dx,
• fever, night sweating -TB
Physical Examination

• DD of Ascitis
 Massive hepatomegaly
 Gaseous distention
 Pregnancy
 Intra abdominal masses
 Shifting dullness
 Puddle sign approx. 120mls
Stigmata of chronic liver disease

• Stigmata of chronic liver disease

Palmar erythema
gynaecomastia
splenomegally,
Spider Naevi
Lab Test

• Blood test: LFTS,TBC,U/E/C

Ascitis fluid testing, Microscopy,cultural
SAAG, Cytology, LAD, Glucose
Management

• Paracentecis- up for 5 litre

• Diuretics Furosemide and Spironolactone
Spontaneous Bacterial peritonitis
• Defination
• Ascitic fluid infection with pure growth of a single organism , ascitic
neutrophil count.250 cell/ul with no evidence of surgically correctable
cause
• Occurs in setting of liver disease, nephrotic syndrome

• Agents
o E.coli klebsiella pneumonae and pneumococcus most common
• anaerobes~ 1%
Clinical Features

85 % of patient SBP
• Fever
• Abdominal pain
• Change in mental status

Treatment
• Antibiotics when cell count is >250 cell/ micro litre before cultures result
• 3rd generation cephalosporins
• Fluroquinolones 5-10days
Treatment
Abx for empirical tx:
• Iv cefotaxime, amoxicillin –clavulanic acid
• Oral norfloxacin(uncomplicated peritonitis)
• No aminoglycosides
• Re-evaluate if ascitic fluid PMN count has not decreased by at least 25
% after 2 days of tx
• Min. duration of tx 5 /7
Hepato Renal Syndrome
• HRS is the final stage of functional renal impairment in pts with
cirhosis and PHT
• Occurs in refractory Ascitis
HRS is characterised by:
• Peripheral vasodilatation, creatinine clearance 40ml/min
• Normal intravascular volume
• Absence of intrinsic renal disease
• urine Na+ <10 mmol/L
HRS Treatment
• Withdraw : Diuretics and nephrotoxic agents
• Infuse saline and or albumin
• Vasoactive agents:- octreotide , talipresin
• TIPS
• liver transplantation only definitive cure
Chronic Hepatic Encephalopathy
• A complication of liver cirrhosis characterized by: mental/ neurological disturbances in presence of liver
failure.

Its Classified as:

• i.
acute (episodic);
persistent (chronic):
subclinical (minimal)

• ii.
Type C. (Cirhosis)
Type A (Acute Liver Failure)
 Type B ( porto systemic shunting)
Ammonia
• Neurotoxic generated in intestines
• Negative protein balance
avoid
• GI bleed
• Infection
• Renal Failure
Management
• Identify and tx ppt factor
• Lactulose titration
• Rifaxamine
• Metronidazole/neomycin
• Protein 1-2 g/kg/per day recommended
Portal hypertension
• defined as the elevation of the hepatic venous pressure gradient (HVPG)
to >5 mmHg.
Causes:
increased intrahepatic resistance to the passage of blood flow through
the liver due to cirrhosis and regenerative nodules
increased splanchnic blood flow secondary to vasodilation within the
splanchnic vascular bed
• Cause of ascites and variceal bleed
• Variceal h’ge is an immediate life-threatening prob with a 20–30%
mortality rate associated with @ episode of bleeding.
Ct portal hypertension: classification
THE END!