Cirrhosis and

Portal Hypertension

Gastroenterology Teaching Project American Gastroenterological Association

CIRRHOSIS AND PORTAL HYPERTENSION

What is Cirrhosis?

WHAT IS CIRRHOSIS?

Cirrhosis

• End stage of any chronic liver disease

• Characterized histologically by regenerative nodules surrounded by fibrous tissue

• Clinically there are two types of cirrhosis:• Compensated• Decompensated

DEFINITION OF CIRRHOSIS

CirrhosisNormal

Nodules

Irregular surface

GROSS IMAGE OF A NORMAL AND A CIRRHOTIC LIVER

CirrhosisNormal

Nodules surrounded by fibrous tissue

HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVER

What is the Natural History of Cirrhosis?

WHAT IS THE NATURAL HISTORY OF CIRRHOSIS?

Compensatedcirrhosis

Decompensatedcirrhosis Death

Chronic liver

disease

Natural History of Chronic Liver Disease

Development of

complications:

• Variceal hemorrhage• Ascites• Encephalopathy• Jaundice

NATURAL HISTORY OF CHRONIC LIVER DISEASE

Development of Complications in Compensated Cirrhosis

AscitesJaundiceEncephalopathyGI hemorrhage

Probability of developing

event

0

20

60

80

100

0 60

40

20 40 80 100 120 140 160

MonthsGines et. al., Hepatology 1987; 7:122

NATURAL HISTORY OF CIRRHOSIS

6040 80 100 120 140 1600

40

60

80

20

200

100

Months

Probability of survival

All patients with cirrhosis

Decompensated cirrhosis

180

Decompensation Shortens Survival

Gines et. al., Hepatology 1987;7:122

Median survival~ 9 years

Median survival~ 1.6 years

SURVIVAL TIMES IN CIRRHOSIS

Liver insufficiency

Variceal hemorrhage

Complications of Cirrhosis Result from Portal Hypertension or Liver Insufficiency

CirrhosisAscites

Encephalopathy

Jaundice

Portal hypertension

Spontaneous bacterial peritonitis

Hepatorenal syndrome

COMPLICATIONS OF CIRRHOSIS

Most complications of cirrhosis result from portal hypertension.

What mechanisms lead to portal hypertension?

MECHANISMS OF PORTAL HYPERTENSION

Cirrhosis - Diagnosis

• Cirrhosis is a histological diagnosis

• However, in patients with chronic liver disease the presence of various clinical features suggests cirrhosis

• The presence of these clinical features can be followed by non-invasive testing, prior to liver biopsy

DIAGNOSIS OF CIRRHOSIS

In Whom Should We Suspect Cirrhosis?

• Any patient with chronic liver disease• Chronic abnormal aminotransferases and/or

alkaline phosphatase

• Physical exam findings• Stigmata of chronic liver disease (muscle

wasting, vascular spiders, palmar erythema)• Palpable left lobe of the liver• Small liver span• Splenomegaly• Signs of decompensation (jaundice, ascites,

asterixis)

DIAGNOSIS OF CIRRHOSIS – CLINICAL FINDINGS

Laboratory• Liver insufficiency

• Low albumin (< 3.8 g/dL)• Prolonged prothrombin time (INR > 1.3)• High bilirubin (> 1.5 mg/dL)

• Portal hypertension• Low platelet count (< 175 x1000/µl)

• AST / ALT ratio > 1

In Whom Should We Suspect Cirrhosis?

DIAGNOSIS OF CIRRHOSIS – LABORATORY STUDIES

Increased intrahepatic resistanceis the initial mechanism leading to

portal hypertension

In Cirrhosis:

MECHANISMS OF PORTAL HYPERTENSION IN CIRRHOSIS

Imaging studies• Liver-spleen scan

• Small liver, irregular uptake• Splenomegaly• Colloid shift to bone marrow

• CAT scan / Ultrasound• Nodular liver• Splenomegaly• Venous collaterals

In Whom Should We Suspect Cirrhosis?

DIAGNOSIS OF CIRRHOSIS – IMAGING STUDIES

Small liver,irregular uptake

Splenomegaly

Colloid shift to bone marrow and ribs

Normal Cirrhosis

Liver-Spleen ScanDIAGNOSIS OF CIRRHOSIS – LIVER-SPLEEN SCAN

CAT Scan in Cirrhosis

Liver with an irregular surface SplenomegalyCollaterals

DIAGNOSIS OF CIRRHOSIS – CAT SCAN

Confirmatory Liver Biopsy Is Not Always Necessary in Cirrhosis

• Liver biopsy is not necessary in the presence of any of the following:− Decompensated cirrhosis (variceal

hemorrhage, ascites, encephalopathy)

− Liver-spleen and/or CAT scan diagnostic of cirrhosis

• Liver biopsy is not necessary for pre-transplant evaluation

DIAGNOSIS OF CIRRHOSIS

Normal Vascular Anatomy

Hepatic vein

Sinusoid

Portal vein

Hepatic artery

Liver

Splenic vein

Coronary vein

Inferiorvena cava

Inferior mesenteric vein

Superiormesenteric

vein

NORMAL VASCULAR ANATOMY OF THE LIVER

Normal Liver

Hepatic vein

Sinusoid

Portal vein

Liver

Splenic vein

Coronary vein

THE NORMAL LIVER OFFERS ALMOST NO RESISTANCE TO FLOW

Portal systemic collaterals

Distorted sinusoidal

architectureleads to

increased resistance

Portal vein

Cirrhotic Liver

Splenomegaly

ARCHITECTURAL LIVER DISRUPTION IS THE MAIN MECHANISM THAT LEADS TO AN INCREASED INTRAHEPATIC RESISTANCE

• Cirrhosis is the most common cause of portal hypertension

• The site of increased resistance in cirrhosis is sinusoidal

• Other causes of portal hypertension are classified according to the site of increased resistance

Causes of Portal Hypertension

CAUSES OF PORTAL HYPERTENSION

Portal Hypertension Is Classified According to the Site of Increased

ResistanceType Example

Pre-hepatic Portal or splenic vein thrombosis

Pre-sinusoidal Schistosomiasis

Sinusoidal Cirrhosis

Post-sinusoidal Veno-occlusive disease

Post-hepatic Budd-Chiari syndrome

CLASSIFICATION OF PORTAL HYPERTENSION

PRE-HEPATIC PORTAL HYPERTENSION

Pre-Hepatic Portal Hypertension

Hepatic vein

Sinusoid

Portal vein

Liver

Thrombus

Portosystemic collaterals

Splenomegaly

SINUSOIDAL PORTAL HYPERTENSION

Cirrhotic liver

Portal vein

Sinusoidal Portal HypertensionPortal systemic collaterals

Splenomegaly

POST-SINUSOIDAL PORTAL HYPERTENSION

Post-Sinusoidal Portal Hypertension

Sinusoid

Portal vein

LiverCentri-lobular

fibrosis

Portosystemiccollaterals

Splenomegaly

POST-HEPATIC PORTAL HYPERTENSION

Post-hepatic Portal Hypertension

Thrombus

Portal vein

LiverSinusoid

Splenic vein