Liver Cirrhosis

Question 1

What is Liver Cirrhosis?

Answer 1

Result of chronic inflammation

Cells replaced with scar tissue (fibrosis) and nodules of scar tissue

Question 2

Most common causes of liver cirrhosis (4)

Answer 2

Alcoholic liver disease
Non Alcoholic Fatty Liver Disease
Hepatitis B
Hepatitis C

Question 3

Rarer causes of liver cirrhosis (7)

Answer 3

Autoimmune hepatitis
Primary biliary cirrhosis
Haemochromatosis
Wilsons Disease
Alpha-1 antitrypsin deficiency
Cystic fibrosis
Drugs (e.g. amiodarone, methotrexate, sodium valproate)

Question 4

Signs of cirrhosis (10)

Answer 4

Jaundice (raised bilirubin)

Hepatomegaly (can eventually shrink)

Splenomegaly (portal hypertension)

Spider Naevi

Palmar Erythema (hyperdynamic cirulation)

Gynaecomastia and testicular atrophy in males due to endocrine dysfunction

Bruising (abnormal clotting)

Ascites

Caput Medusae (portal hypertension)

Asterixis – “flapping tremor” in decompensated liver disease

Question 5

Expected blood results (6)

Answer 5

Liver biochemistry - often normal (decompensated cirrhosis ALT, AST, ALP, bilirubin deranged)

Albumin level drops and the prothrombin time increases as the synthetic function becomes worse

Hyponatraemia =fluid retention

Urea and cr deranged in hepatorenal syndrome

Viral markers and autoantibodies can help est. cause

Alpha-fetoprotein tumour marker for hepatocellular carcinoma (6 monthly)

Question 6

What is found on ultrasound?

Answer 6

Nodularity of the surface of the liver

A “corkscrew” appearance to the arteries with increased flow as they compensate for reduced portal flow

Enlarged portal vein with reduced flow

Ascites

Splenomegaly

Question 7

What does a fibroscan do?

Answer 7

FibroScan” can be used to check the elasticity of the liver

Helps assess the degree of cirrhosis.

NICE recommend retesting every 2 years in patients at risk of cirrhosis:
Hepatitis C
Heavy alcohol drinkers (men drinking > 50 units or women drinking > 35 units per week)
Diagnosed alcoholic liver disease
Non alcoholic fatty liver disease and evidence of fibrosis on the ELF blood test
Chronic hepatitis B (yearly)

Question 8

Why is endoscopy used to assess for in liver cirrhosis?

Answer 8

Assess for and treat oesophageal varices when portal hypertension is suspected

Question 9

What is the Child-Pugh score?

Answer 9

Indicates severity of liver cirrhosis based on:
Bilirubin
Albumin
INR
Ascites
Encephalopathy

Question 10

What is the MELD score?

Answer 10

Recommended by NICE to be used every 6 months in patients with compensated cirrhosis
Bilirubin, creatinine, INR and sodium and whether they are requiring dialysis

Gives a percentage estimated 3 month mortality and helps guide referral for liver transplant

Question 11

General management of liver cirrhosis

Answer 11

Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma

Endoscopy every 3 years in patients without known varices

High protein, low sodium diet

MELD score every 6 months
Consideration of a liver transplant

Manage complications

Question 12

Complications of liver cirrhosis

Answer 12

Malnutrition
Portal Hypertension, Varices and Variceal Bleeding
Ascites and Spontaneous Bacterial Peritonitis (SBP)
Hepato-renal Syndrome
Hepatic Encephalopathy
Hepatocellular Carcinoma

Question 13

Where do varices occur?

Answer 13

Where the portal system anastomoses with the systemic venous system

Gastro oesophageal junction
Ileocaecal junction
Rectum
Anterior abdominal wall via the umbilical vein (caput medusae)

Question 14

What is the treatment for stable varices?

Answer 14

Propranolol reduces portal hypertension by acting as a non-selective beta blocker

Elastic band ligation of varices

Injection of sclerosant (less effective than band ligation)

Transjugular Intra-hepatic Portosystemic Shunt (TIPS)

Question 15

What is the treatment for bleeding oesophageal varices?

Answer 15

Terlipressin (vasopressin analogue) causes vasoconstriction - slows bleeding

Correct any coagulopathy

broad spectrum antibiotics prophylactic

Consider ICU/intubation

Urgent endoscopy
Sclerosant used to cause “inflammatory obliteration” of the vessel
Elastic band ligation of varices

Question 16

What is used in treating oesophageal varices if endoscopy fails?

Answer 16

Sengstaken-Blakemore Tube is an inflatable tube inserted into the oesophagus to tamponade the bleeding varices

Question 17

What is the management of ascites/

Answer 17

Low sodium diet

Anti-aldosterone diuretics (spironolactone)

Paracentesis (ascitic tap or ascitic drain)

Prophylactic antibiotics against spontaneous bacterial peritonitis (ciprofloxacin or norfloxacin) in patients with less than 15g/litre of protein in the ascitic fluid

Consider TIPS in refractory ascites

Consider transplantation in refractory ascites

Question 18

What is spontaneous bacterial peritonitis? (SBP)

Answer 18

Infection developing in the ascitic fluid and peritoneal lining without any clear cause

Occurs in around 10% of patients with ascites secondary to cirrhosis

Mortality of 10-20%

Question 19

Presentation of SBP?

Answer 19

Can be asymptomatic so have a low threshold for ascitic fluid culture

Fever

Abdominal pain

Deranged bloods (raised WBC, CRP, creatinine or metabolic acidosis)

Ileus

Hypotension

Question 20

Most common organisms causing SBP

Answer 20

Escherichia coli
Klebsiella pnuemoniae
Gram positive cocci (such as staphylococcus and enterococcus)

Question 21

Management of SBP

Answer 21

Take an ascitic culture prior to giving antibiotics

Usually treated with an IV cephalosporin such as cefotaxime

Question 22

What is hepatorenal syndrome?

Answer 22

Hypertension in the portal system leads to dilation of the portal blood vessels due to blood pooling

Loss of blood volume in other areas of the circulation, including the kidneys

Leads to hypotension in the kidney and activation of the renin-angiotensin system

Leads to vasoconstriction, which combined with low circulation volume leads to starvation of blood to the kidney

Rapid deterioration of kidey function - fatal within a week without transplant

Question 23

What is hepatic encephalopathy?

Answer 23

AKA portosystemic encephalopathy

Caused by build-up of toxins in the brain inc. AMMONIA ( produced by intestinal bacteria when they break down proteins and is absorbed in the gut)

Functional impairment of the liver cells prevents them metabolising the ammonia into harmless waste products
Collateral vessels between the portal and systemic circulation mean that the ammonia bypasses liver altogether and enters the systemic system directly

Question 24

How does hepatic encepahlopathy present?

Answer 24

Acutely, it presents with reduced consciousness and confusion

Chronically with changes to personality, memory and mood

Question 25

What are the precipitating factors to hepatic encephalopathy? (6)

Answer 25

Constipation
Electrolyte disturbance
Infection
GI bleed
High protein diet
Medications (particularly sedative medications)

Question 26

What is the management of hepatic encephalopathy?

Answer 26

Laxatives (i.e. lactulose) promote the excretion of ammonia. The aim is 2-3 soft motions daily. They may require enemas initially

Antibiotics (i.e. rifaximin) reduces the number of intestinal bacteria producing ammonia

Rifaximin is useful as it is poorly absorbed and so stays in the GI tract

Nutritional support - May need nasogastric feeding.