CIRRHOSIS OF LIVER

Cirrhosis
Chronic generalized liver disease A condition that is defined histopathologically and has a

variety of clinical manifestations and complications, some of which can be life threatening.
Pathologic features : development of fibrosis to the point

that there is architectural distortion with formation of regenerative nodules ( micronodular / macronodular )
This results in decrease in hepatocellular mass, thus

function .

Epidemiology
40% cases asymptomatic It is the 12th leading cause of death in United

States.
Approximately 30,000 to 50,000 deaths per year
Additional 10,000 deaths due to liver cancer

secondary to cirrhosis

Etiology of Cirrhosis
Alcoholic liver disease Viral hepatitis Billiary disease Primary hemochromatosis Cryptogrnis cirrhosis Wilsons alfa 1AT def

60-70% 10% 5-10% 5% 10-15% rare

Pathogenesis

Ethyal alcohol is a common cause of acute/chronic liver disease Patterns of alcoholic liver disease : 1. fatty change 2. Acute hepatitis 3. Chronic hepatitis with fibrosis 4. Cirrhosis, chronic liver failure All reversible except cirrhosis stage

Pathogenesis of Alcoholic cirrhosis

Clinical features of cirrhosis

Lab

Imaging
Ultrasonogram examination

- Liver may show coarse ecotexture - Dilated portal veins - Splenomegaly - Ascites CT SCAN may show hepatosplenomegaly and dilated collaterals are seen in chronic liver disease Upper GI Endoscopy : oesophageal varices may seen LIVER BIOPSY IS CONFIRMATORY

Complications
Portal hypertension and esophageal varices
Peripheral edema and ascites Hepatic encephalopathy Fetor hepaticus

Treatment of liver cirrhosis

Removal of the etiological factors
can stop or delay further progression may lead to regression may reduce complications

Prevention and treatment and of

complications

Ascites - Treatment
Small amounts of ascites dietary sodium

restriction ( <2g/day ) Moderate : diuretic is essential Spiranolactone 100-200 mg/day OD Furosemide 40-80 mg/day - if peripheral edema + Pt is compliant but ascitic fluid + , then Spiranolactone 400 -600 mg/day Furosemide 120-160 mg/day If ascites still + , then it is REFRACTORY ASCITES

Ascites - treatment
Refractory ascites Large volume paracentesis

TIPS Liver Transplantation Prognosis pts of cirrhosis with ascites- poor <50 % of pts survive 2 yrs after the onset of ascites.

SBP (Spontaneous Bacterial Peritonitis)

Pt can present with altered sensorium, elevated WBC,

abdominal pain/discomfort Treatment : cephalosporins In pts with an episode(s) of SBP and recovered , once weekly- administration of antibiotic as prophylactic measure

Hepatorenal Syndrome
Functional renal failure without renal pathology 10% of pts with cirrhosis / advanced liver failure Diagnosis : presence of large amount of ascites

progressive rise in creatinine urinary sodium <10 mEq Type 1 HRS : progressive impairment of renal function & significant reduction in creatinine clearance within 1- 2 wks . BAD PROGNOSIS Type 2 HRS : reduction in GFR, with rise in S.Creat BETTER PROGNOSIS

Hepatorenal Syndrome
Seen in refractory ascites

Exclude causes of ARF

Treatment: Midodrine, an alpha agonist along with Octerotide and IV

Albumin Liver transplantation

HEPATIC ENCEPHALOPATHY
TreatmentCORRECT/ AVOID PRECIPITATING

FACTORS
Dietary protein restriction-30 - 40 gm protein / day Non absorbable disaccharide LACTULOSE 15 to 45

ml BID / QID
Lactulose enema

Neomycin 1 gm 6th hrly

Metronidazole 250 mg 8th hrly Bowel wash / Lactobacillus

HEPATOPULMONARY SYNDROME
Clubbing, cyanosis, spider nevi, orthodeoxia Hypoxia in standing position-ORTHODEOXIA Hypoxia is due to intrapulmonary shunting through direct arteriovenous communications Intra Pulmonary Vascular dilatation in the absence of intrinsic cardio pulmonary disease Resistant hypoxaemia (PaO2 < 9.3 kPa or 70 mmHg), intrapulmonary vascular dilatation and chronic liver disease with portal hypertension Treatment : liver transplantation

Prognosis Child-Pughs classification

Categories
1

Classification Points
2 3

Encephalopathy
Ascites Bilirubin (mg/dl)

None
Absent <2 (4) >3.5 1-4

Grade I & II
Slight-moderate 2-3 (4-10) 2.8-3.5 4-6

Grade III & IV

Tense >3 (>10) <2.8 >6

Albumin (g/dl)
Prothrombin Time

Grade A

5-6

Grade B
Grade C

7-9
10-15

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