CIRRHOSIS OF LIVER

Avaneesh Jakkoju, M.D.

Definition

“ (cirrhosis is defined as) the pathologic features consist of the development of fibrosis to the point that there is architectural distortion with the formation of regenerative nodules.”

Harrison’s principles of internal medicine, 17th edition

“widespread disruption of normal liver structure by fibrosis and the formation of regenerative nodules that is caused by any of various chronic progressive conditions affecting the liver. “

Miriam Webster dictionary

Global prevalence of Cirrhosis

Causes of Cirrhosis

Chronic viral hepatitis Alcoholic liver disease Nonalcoholic steatohepatitis Billiary cirrhosis

Primary biliary cirrhosis Primary sclerosis cholangitis Autoimmune cholangiopathy

Cardiac cirrhosis Autoimmune hepatitis Inherited metabolic liver disease

Hemochromatosis Wilson’s disease α1 Antitrypsin deficiency Cystic fibrosis

Medications (Isoniazide, Methotrexate) Cryptogenic/idiopathic cirrhosis Hereditary hemorrhagic telengectasia

Morphologic classification

Micronodular cirrhosis Macronodular cirrhosis Mixed

Clinical features

Anorexia Weight loss Weakness Fatigue Muscle cramps Easy bruising Amenorrhea/

Oligomenorrhea Decreased libido

Jaundice Dark/cola colored urine Pruritis Hematemesis Melena Hematochezia Abdominal distention Lower extremity

edema Confusion and sleep

disturbance

Extra hepatic manifestations… Depending on the etiology of cirrhosis

patients have different extra hepatic manifestations such as Cryoglobulinemia from Hep C Diabetes mellitus and arthropathy from

hemochromatosis Hemolytic anemia or thyroiditis in

autoimmune hepatitis.

Physical examination

Decreased blood pressure Hepatomegaly Splenomegaly Gynecomastia Loss of chest or axillary hair Testicular atrophy Cruveilhier-Baumgarten murmur

Jaundice

Spider angiomata

Palmar erythema

Dupuytren’s contracture

Caput medusa

Muehrcke nails

Terry nails

Clubbing

Signs of advanced disease

Fetor hepaticus Fetor hepaticus refers to a sweet, pungent

smell to the breath of a patient with cirrhosis. It is caused by increased concentrations of dimethyl sulfide, the presence of which suggests underlying severe portal-systemic shunting.

Acites

Asterexis

Laboratory findings

Aminotransferases AST and ALT are moderately elevated in cirrhosis.

Normal levels should not rule out the diagnosis. Alakaline phosphotase Gamma glutamyl transpeptidase Bilirubin Albumin Prothrombin time Hyponatremia Thrombocytopenia Anemia

Imaging

Ultrasound First choice for initial evaluation High resolution USG has a sensitivity of 91% and

specificity of 94% CT scan

Not superior to USG Higher cost, radiation and contrast exposure

MRI ? Accurate diagnosis and correlation with severity Useful for measuring liver iron stores MRA is more sensitive than USG for portal vein

thrombosis Nuclear studies

Liver biopsy

Gold standard is examination of explanted liver

Percutaneous biopsy Image guided biopsy

Determining the cause

Important Can be done in 85 to 90% cases When found treatment should be aimed

at that particular cause Also gives information regarding

prognosis If initial evaluation with history and labs

is inconclusive look for rarer causes of cirrhosis

Management strategies

Detailed history Thorough physical examination Labs Imaging Biopsy if needed Determine the cause Appropriate referrals where needed Explain diagnosis and prognosis Life style modifications; no EtOH, no hepatotoxic

drugs Follow response to treatment If everything fails, consider transplantation on case

by case basis

“I tried to pay attention, but attention paid me.”

-Lil’ WayneShe will; The carter IV

Thank you