Cirrhosis

Question 1

what is definately raised in liver cirrhosis?

Answer 1

Albumin and PT will defo be abnormal

Question 2

define cirrhosis?

Answer 2

End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes – this is IRREVERSIBLEliver damage

Question 3

describe the histology of cirrhosis?

Answer 3

bridging fibrosis + nodular regeneration

Question 4

when is cirrhosis considered decompensated?

Answer 4

becomes complicated by any of:
J BAE

Jaundice

GI bleed (bleeding varices)

Ascites

Encephalopathy

Question 5

what can precipitate decompensation?

Answer 5

GI bleeding, constipation, high-protein meal, electrolyte imbalances, alcohol and drugs, tumour development or portal vein thrombosis

Question 6

summarise the epidemiology of cirrhosis?

Answer 6

Among the top 10 leading causes of deaths worldwide

Question 7

outline the aetiology/risk factors for liver cirrhosis?

Answer 7

Chronic alcohol misuse (most common in the UK)

Chronic viral hepatitis (hep B/C - most common worldwide)

Autoimmune hepatitis

Drugs (e.g. methotrexate, methyldopa, amiodarone and other hepatotoxic drugs)

Inherited

vascular

chronic biliary diseases- PBC , PSC, Biliary atresia

NASH

Question 8

what drugs cause liver cirrhosis?

Answer 8

methortrexate

methyldopa

amiodarone

other hepatotoxic drugs

Question 9

what are the inherited causes of liver cirrhosis?

Answer 9

alpha1-antitrypsin deficiency

Haemochromatosis

Wilson’s disease – autosomal recessive condition characterised by excess copper

Galactosaemia

Cystic Fibrosis

Question 10

what are the vascular causes of liver cirrhosis?

Answer 10

Budd-Chiari Syndrome – occlusion of hepatic veins that drain liver

Hepatic Venous Congestion

Question 11

what are the early non-specific symptoms of liver cirrhosis?

Answer 11

Anorexia

Nausea

Fatigue

Weakness

Weight loss

Question 12

what are the symptoms of liver cirrhosis which are due to decreased synthetic liver function?

Answer 12

Easy bruising

Abnormal swelling

Ankle oedema – cirrhosis slows the normal blood flow through the liver, thus increasing pressure in the vein that brings blood from the intestines and spleen to the liver

Leuconychia – due to hypoalbuminaemia

Question 13

what are the symptoms of liver cirrhosis which are due to reduced detoxifcation?

Answer 13

Jaundice

Personality change

Altered sleep pattern

Amenorrhoea

Galactorrhoea

Question 14

what are the symptoms of liver cirrhosis due to portal hypertension?

Answer 14

Abdominal swelling

Haematemesis

PR bleeding or melaena

Question 15

what are the signs of chronic liver disease?

Answer 15

Asterixis/ascites

Bruises

Clubbing and caput medusae

Dupuytren’s contracture

In the early stages management is largely conservative but if function is affected then surgery is indicated. Surgery involves excising the thickened aponeurosis and would be followed by a period of splinting and physiotherapy to restore hand function. Re-thickening can occur so surgery may need to be repeated.

Palmar Erythema

Fat spleen – splenomegaly and fetor hepaticus

Gynaecomastia

Hair loss – bodily hair and hepatomegaly (may be shrunken in the later stages)

Itching due to bile products being deposited in the skin (cholestatic pruritis)

Jaundice

Leukonychia

Mini testicles – testicular atrophy/ muscle wasting

Spider naevi – consist of a central arteriole from which numerous vessels radiate, occur most commonly in skin drained by the superior vena cava, up to 5 are normal

Other causes: contraceptive steroids, pregnancy

Parotid enlargement

Terry’s nails – white proximally but distal 1/3 reddened

Xanthelasma

Question 16

describe the bloods in liver cirrhosis?

Answer 16

FBC: low platelets + Hb = because of hypersplenism as a result of portal hypertension

LFTs - may be normal but often get:

• High AST, ALT, ALP, GGT and bilirubin
• Low albumin

Seum sodium – reduced and worsens as cirrhosis progressed

Clotting: prolonged PT

Serum AFP (alpha-fetoprotein = tumour marker for liver cancer):

• Raised in chronic liver disease
• High levels may suggest hepatocellular carcinoma

Question 17

what are the investigations to determine the cause of liver cirrhosis?

Answer 17

Viral serology

a1-antitrypsin

Caeruloplasmin- This is a copper-carrying complex that is LOW in Wilson’s disease

Iron studies: serum ferritin, iron, total iron binding capacity (TIBC) - check for haemochromatosis

Anti-mitochondrial antibody (PBC)

ANA, ASMA (autoimmune hepatitis)

Question 18

what do we look for in an ascitic tap?

Answer 18

Microscopy, culture and sensitivity - check for infection

Biochemistry (protein, albumin, glucose, amylase)

Cytology

IMPORTANT: ascitic tap with neutrophils > 250/mm3 = spontaneous bacterial peritonitis (SBP)

Question 19

what does an ascitic tap with neutrophils more than 250 indicate?

Answer 19

spontaneous bacterial peritonitis ( SBP)

Question 20

What test confirms the clinical diagnosis?

Answer 20

liver biopsy

Question 21

what are the 2 ways a liver biopsy can be performed?

Answer 21

Percutaneously

Transjugular - if clotting deranged or ascitic

Question 22

what are the histopsthological features of cirrhosis?

Answer 22

Periportal fibrosis

Loss of normal liver architecture

Nodular appearance

• Grade - indicates degree of inflammation
• Stage - degree of architectural distortion (from mild portal fibrosis –> cirrhosis)

Question 23

what are the investigations for liver cirrhosis?

Answer 23

bloods

investigations to find cause

ascitic tap

liver biopsy

imaging- US, CT, MRI

Endoscopy

Question 24

what imaging is done and what are they used to detect?

Answer 24

US, CT or MRI - to detect complications such as:

• Ascites
• HCC
• Hepatic or portal vein thrombosis
• Exclude biliary obstruction

MRCP (if PSC suspected)

Question 25

what is endoscopy used for?

Answer 25

examine varices

Question 26

what is the scoring system to investigate the prognosis of chronic liver disease/cirrhosis and what are the 5 factors it is based on?

Answer 26

**Child-Pugh Grading** * Albumin * Bilirubin * PT * Ascites * Encephalopathy

Question 27

what are the 3 classes that cirrhosis can be divided into using the child pugh grading system?

Answer 27

Class A: 5-6 Class B: 7-9 Class C: 10-15

Question 28

outline the management plan for liver cirrhosis?

Answer 28

Treat the CAUSE if possible Avoid alcohol, sedatives, opiates, NSAIDs and drugs that affect the liver Imms against Hep A and B for susceptible patients Nutrition is important Enteral supplements should be given NG feeding may be indicated Treating Complications- encephalopathy, ascites, spontaneous bacterial peritonitis Surgical

Question 29

describe the management of encephalopathy?

Answer 29

Treat infections Exclude GI bleed **Use lactulose and phosphate enemas** Avoid sedation

Question 30

how does lactulose treat encephalopathy?

Answer 30

lactulose reduces the absorption of ammonia from the gut. This helps prevent encephalopathy caused by ammonia reaching the brain

Question 31

describe the treatment of ascites?

Answer 31

**Diuretics** (spironolactone with/without furosemide) Dietary sodium restriction Therapeutic paracentesis (with human albumin replacement) Monitor weight Fluid restrict if plasma sodium \< 120 mmol/L Avoid alcohol and NSAIDs

Question 32

describe the treatment of SBP?

Answer 32

Antibiotics (e.g. cefuroxime and metronidazole) Prophylaxis against recurrent SBP with ciprofloxacin

Question 33

Describe the surgical management of liver cirrhosis?

Answer 33

Consider **TIPS** (transjugular intrahepatic portosystemic shunt) - this helps **reduce portal hypertension** However, it may precipitate encephalopathy because it is providing a route for blood from the GI tract to bypass the liver **Liver transplantation** is the only curative method

Question 34

what are the possible complications of liver cirrhosis/

Answer 34

**Portal hypertension with ascites** **Hepatic encephalopathy:** This condition is precipitated by the liver's inability to convert toxic ammonia into urea which can freely cross the BBB causing CNS symptoms. Variceal haemorrhage **SBP** **HCC** Renal failure **(hepatorenal syndrome)** Pulmonary hypertension **(hepatopulmonary syndrome)**

Question 35

summarise the prognosis of patients with liver cirrhosis?

Answer 35

Depends on aetiology and complications Generally poor prognosis * Overall 5 year survival = 50% * If ascites, 2 year survival = 50% Poor prognostic indicators: encephalopathy, serum Na+ \<110 mmol/L, serum albumin \<25g/L, high INR