Liver Cirrhosis Assist. Prof. Mona Arafa Tropical Medicine Department.
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Transcript of Liver Cirrhosis Assist. Prof. Mona Arafa Tropical Medicine Department.
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Liver Cirrhosis
Assist. Prof. Mona Arafa
Tropical Medicine Department
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Objectives
1. Understand the basic mechanisms of Liver cirrhosis
2. Recognize the classic presentations of Liver cirrhosis and its complications
3. Get an idea about the management of these complications
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Definition:
1. Diffuse disorder of liver characterised by;
2. Complete loss of normal architecture,
3. Replaced by extensive fibrosis with,
4. Regenerating parenchymal nodules.
▼
Loss of normal function
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Pathophysiology
►Slow, insidious, progressive, chronic►Fibrous bands replace normal liver
structure► Cell degeneration occurs► Liver attempts to regenerate cells but
cells are abnormal and disorganized► Causes abnormal blood and lymph flow► Results in more fibrous tissue formation
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Normal Liver
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Cirrhosis
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Normal Liver Histology
CV
PT
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Cirrhosis
Fibrosis
Regenerating Nodule
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Classification of Cirrhosis
◘ WHO divided cirrhosis into 3 categories based on morphological characteristics of the hepatic nodules
1. Micronodular
2. Macronodular
3. Mixed
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Causes of Cirrhosis1. Chronic viral hepatitis(HCV, HBV±HDV)2. Metabolic: hemochromatosis, Wilson dis,
alfa-1-antitrypsin, NASH3. Prolonged cholestasis (PBC, PSC)4. Autoimmune hepatitis5. Hepatic venous outflow obstruction
(VOD, BCS, Constrictive pericarditis)6. Drugs and toxins7. Alcohol
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Clinical Presentation
Stigmata of chronic liver disease. Abnormal LFTs and CBC. Radiographic abnormalities. Complication of cirrhosis. Cirrhotic appearance of the liver at
laparotomy or laparoscopy.
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Clinical Features
*Fatigue, anorexia, malaise.*Weight loss & muscle wasting.*Jaundice & dark urine.*Parotid enlargement & diarrhea.*Anemia, leucopenia, thrombocytopenia.*Bleeding gum, epistaxis, ecchymosis.*Spider angioma, palmar erythema, white
nails, dilated veins.
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Clinical Features Cont.
*Gynecomastia, change in body hair patterns.
*Amenorrhea, loss of libido, testicular atrophy, impotence.
*Swelling of LL and abdomen.
*Dyspnea & hypoxia.
*Increased susceptibility to infections.
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“White Nails”
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Palmar Erythema
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Clinical Features of Cirrhosis
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Prominent abdominal veins.
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Complications
Portal hypertension Ascites Varices
Coagulation defects Hepatic encephalopathy Hepatocellular carcinoma Hepatorenal syndrome
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Diagnosis of cirrhosis Physical examination
*Stigmata of chronic liver disease*Features of portal hypertension*Hepatic encephalopathy
Laboratory evaluation*Tests for hepatocellular necrosis*Tests for cholestasis*Tests for synthetic function*Special tests for the cause*Screening test for HCC; AFP
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Diagnosis of cirrhosis Imaging modalities
*Abdominal ultrasound.
*Computed tomography (CT).
*Magnetic resonance imaging (MRI).
*Fibroscan Esophagogastroduodenoscopy (EGD). Liver Biopsy.
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Prognosis
*Depends on the development of cirrhotic complication
*Assessed by Child-Turcotte-Pugh score*Model for End-stage Liver Disease (MELD)
Based on serum bilirubin, creatinine, and INRDetermine optimal timing for liver
transplantation
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Child-Pugh score
score123
Albumin.>3.53.5-2.8<2.8
Bilrubin<22-3>3
AscitesAbsentMild-Moderate
Severe/Refractory
HEAbsentMild (I-II)Severe (III-IV)
PT prolongation
<4 sec.<(1.7)
4-6 sec. (1.7-2.3)
>6 sec.>( 2.3)
Class A: 5-6 Class B: 7-9 Class C: 10-15
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Management
Specific treatment*Antiviral in HBV-cirrhosis*Corticosteroids in AIH*Phlebotomy in hemochromatosis
Treatment of complications Screening for HCC Liver transplantation
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Portal hypertension
Definition : Increase in hepatic sinusoidal pressure to ≥ 6mm Hg.
N.B : Portal pressure must be at least 10mm Hg for gastroesophegeal varices to develop and at least 12mm Hg for varicees to bleed.
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Portal hypertension is classified as : prehepatic , hepatic and post hepatic.
Prehpatic causes include:
*Splenic vien thrombosis*Portal vein thrombosis
)associated with hpercoagulable states and with malignancy(
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Post hepatic causes:
*Chronic right sided heart failure*TR
*Obstructing lesions of hepatic viens and I.V.C )Budd-chiari syndrome (
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Management of complications Varices
May be esophageal, gastric, colo-rectal Diagnosis
*History : Hematemesis, melena
*Physical examination
*Ultrasound abdomen
*Endoscopy
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Esophageal Varices
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Management of complications Varices
Management*ABC*Two IV Lines*Blood group*Resuscitation (fluid, blood, FFP)*IV vasoconstrictors (Octreotide)*Endoscopic therapy (EST, EBL)*Shunting (surgical, TIPS)
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EST & EBL
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Management of complications Varices
Prevention
*Endoscopy for every cirrhotic patient at diagnosis and periodically
*Treat underlying disease
*Beta blockers
*Endoscopic Band Ligation (EBL)
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Ascites
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Management of complications Ascites
Diagnosis*Bulging flanks, shifting dullness, fluid wave*Ultrasound*Ascites taping (SAAG, SBP)
Treatment*Salt restriction (<2gm/d)*Diuretics (spironolactone, loop diuretics)*Paracentesis
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Paracentesis
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Hepatic encephalopathy
Neuropsychiatric abnormalities secondary to liver disease
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BRAIN
LIVER
Toxic N2 metabolites
From Intestines
Porta systemic shunts
Pathogenesis of Hepatic Encephalopathy
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Management of complications Hepatic encephalopathy
Treatment*Identify and treat precipitating factor*Low protein diet*L-ornithine L-aspartate*Antibiotics
(Neomycin, metronidazole, rifaximin)*Lactulose
*Enemas*Transplantation
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Thank You