Cirrhosis

Question 1

Define cirrhosis

Answer 1

End stage of chronic liver disease characterised by fibrosis and conversion of normal liver
architecture to abnormal nodules

Question 2

What are the causes/risk factors of cirrhosis?

Answer 2

Causes
• Chronic alcohol misuse (most common cause in UK)
• Chronic viral hepatitis
• Autoimmune hepatitis
• Drugs e.g. methotrexate
• Inherited conditions e.g. α1-antitrypsin deficiency, haemochromatosis, Wilson’s
disease, cystic fibrosis
• Chronic biliary diseases e.g. primary biliary cirrhosis, primary sclerosing cholangitis,
biliary atresia
• Cryptogenic (idiopathic)
• Budd-Chiari or hepatic vein thrombosis
• NASH (non-alcoholic steatohepatitis)

Risk factors
• Alcohol misuse
• IVDU
• Unprotected sex
• Obesity
• Blood transfusion

Question 3

What are the causes of decompensation?

Answer 3

• Infection
• Alcohol and drugs (opiates)
• GI bleeding
• High protein diet
• Dehydration
• Constipation (especially encephalopathy)
• Electrolyte imbalances
• Portal vein thrombosis
• Tumours

Question 4

What are the signs and symptoms of cirrhosis?

Answer 4

Stigmata of Chronic Liver Disease:
• Asterixis, Ascites, Ankle Oedema, Atrophy of testicles
• Bruises and Petechiae
• Clubbing, Colour change in the nails (Leukonychia), Caput Medusae
• Dupuyten’s Contractures
• Erythema (Palmar), Encephalopathy
• Foetor hepaticus
• Gynaecomastia and hair loss
• Hepatomegaly
• Increase size of parotids, Itching/pruritus due to BR deposition in the skin.
• Jaundice

• Spider Naevi and Striae
• Xanthomas and Xanthelasma
• Liver flap

effects of portal hypertension:
• oesophageal varices
• melena
•  splenomegaly
•  dilated abdominal veins

• fatigue
• weakness
• wight loss
• cachexia

Question 5

What investigations are carried out for cirrhosis?

Answer 5

• FBC - Anaemia, Leukopaenia and Thrombocytopaenia due to hypersplenism.
• LFTs - Normal or deranged, ALT and AST levels are elevated with hepatocellular damage.
( Usually, ALT elevation > AST elevation; If the AST: ALT ration > 2 then alcoholic liver disease is suspected)

*In an obstructive cause of cirrhosis, like PBC and PSC, the GGT and ALP are elevated. AST and ALT are normal.
**In compensated cirrhosis, the BR may be normal; in decompensated cirrhosis it’s often high.
Serum Albumin is often low.

• U&Es - Hyponatraemia is common in cirrhotic patients with ascites.
• Clotting Screen - Prolonged PT due to reduced synthesis of clotting factors.
• Serum AFP - α-Fetoprotein –can be elevated in chronic liver disease; very high in HCC.

Other Investigations: 
To determine the cause: 
• Viral Serology 
• α 1-Antitrypsin 
• Caeruloplasmin and urinary copper - Wilson’s Disease 
• Iron Studies - Fe, Ferritin, Transferrin (TIBC), Transferrin Saturation –HH. 
• AIH: Anti-self antibody serology
• Lipid studies: NASH. 

• Liver USS - May show hepatomegaly or (later on) a small liver, Splenomegaly, Focal Liver lesions, Hepatic vein thrombosis, Reversed flow in the portal vein, Ascites
• MRI/CT - Detects complications and visualises regeneration nodule islands.
• MRCP -If PSC is suspected.
• OGD - Examine for varices, portal hypertensive gastropathy.
• Ascitic Tap - If neutrophils >250/mm3, this indicates spontaneous bacterial peritonitis (SBP).
• Liver Biopsy - Percutaneous or transjugular if clotting deranged or ascites present.
• Histopathology- Periportal fibrosis, Loss of normal liver architecture, Nodular appearance –regeneration islands.

Question 6

What is the management for cirrhosis?

Answer 6

Conservative 
General: 
• Treat the cause if possible. 
• Alcohol Abstinence 
• Nutritional Support 
• Avoid: NSAIDs, sedatives and opiates 
• Colestyramine for pruritus 
• Screen for HCC: USS and serum AFP every 6 months. 

Specific:
• PBC: Ursodeoxycholic Acid
• Wilson’s Disease: Penicillamine

Treat the Complications:
Ascites:
• Fluid Restriction
• Low salt diet
• Diuretics: Spironolactone ± furosemide if necessary
• Therapeutic paracentesis may be required with concomitant albumin infusion.

Encephalopathy:
• Treat decompensation-inducing cause e.g. infection.
• Exclude GI bleeds.
• Lactulose
• Phosphate enemas (relieve constipation which is thought to increase ammonia levels, causing encephalopathy).

SBP:
• Prophylaxis: Ciprofloxacin –high risk patients: low albumin or clotting deficiency.
• Treatment: Metronidazole and Cefuroxime

*No specific Medical Treatment for Cirrhosis.

Surgical
• TIPS: Transjugular Intrahepatic Portosystemic Shunt
**Complications: This reduced the liver’s ability to detoxify ammonia, since a lot of the ammonia will be automatically shunted from the portal circulation to the systemic circulation. This increases the risk of encephalopathy.

• Liver Transplant - this is the only cure for cirrhosis

Question 7

What are the complications of cirrhosis?

Answer 7

Decompensated chronic liver disease
• Portal hypertension
• Variceal haemorrhage
• Ascites -> spontaneous bacterial peritonitis
• Portosystemic encephalopathy
• Hepatorenal syndrome
• Hepatocellula carcinoma
• Hepatopulmonary syndorme - pulmonary hypertension
• Liver Failure: Coagulopathy, Jaundice, Encephalopathy, Oedema