Lec 9 Part2 Liver Cirrhosis

7/30/2019 Lec 9 Part2 Liver Cirrhosis

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Liver CirrhosisLiver cirrhosis () :chronic progressive disease ;means the

disease will continue unless you know and discover what is the

underlying cause and treat it . it is not a simple disease, it is a very

serious disease .

When we could say that the patient has liver cirrhosis ?

- If we find some pathological findings from a biopsy or clinical pictures :

Necro-inflammatory reaction. Fibrosis. Loss of the lobular and vascular architecture of liver lobules ; because

the lobules is not in the normal architecture then they will not function

properly (they are not healthy) ,so the liver will continue to fail.

Formation of Regenerating nodules .

Causes of liver cirrhosis- Liver cirrhosis is the end result of many etiological factors in the liver :

1. Viral hepatitis: B and C; the commonest all over the world** viral hepatitis A doesnt lead to liver cirrhosis.


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2.Alcohol; it is very common in areas where alcohol is essentialfor life like in Scotland, wales (alcohol is the number one as a

cause for liver cirrhosis in these countries) .

3. Biliary diseases: primary or secondary ;liver contains hepatocytes and biliary system , so if

there is any diseases in the biliary system this will lead

to necrosis, inflammation and cirrhosis in the liver.

sometimes this biliary disease happened due toobstruction in the biliary tract, and sometimes it is not

due to obstruction but due to difficulty in the flow of

the bile and this what we call it (primary biliary

cirrhosis) >> there is no underlying cause , it is

thought to be autoimmune in origin.

While the (secondary biliary cirrhosis) occurs due tostrictures(fibrosis) or stones.

4.Autoimmune hepatitis .5. Vascular causes: CHF, Budd-Chiari syndrome, Veno-occlusive

disease.

As you know there is inferior vena cava passing behind theliver , and the liver gives the hepatic veins to take blood

from the liver into the inferior vena cava .

Hepatic veins are the last vessels enter inferior vena cavabefore it enters the heart, so in heart failure (the heart is not


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pumping blood properly) there will be stagnation of blood

behind the liver in the inferior vena cava, so there will be

congestion in the hepatic veins and this congestion will be

reflected on the liver and it will start to deteriorate due tocongestive heart failure.

Sometimes this process(stagnation of blood) occur due toocclusion of hepatic veins themselves >> this condition is

called (Budd-Chiari syndrome).

in another condition there is occlusion in the small vessels ofthe liver >> this condition is called (Veno-occlusive disease).

6. Drugs and toxins ; we have a lot of drugs which may causeliver cirrhosis such as chemotherapeutic agents used for

cancer therapy like(methotrexate , amiodarone) and isoniazide

that is used in TB therapy.

- Also there is a lot of toxins cause liver cirrhosis , some people

use herbal medicines frequently that may contain toxins

especially a type of mushroom which is very toxic to the liver.

7. Hereditary and metabolic (GENETIC IN ORIGIN) :A. hemochromatosis ; increase absorption of iron in the

intestine that will lead to necrosis of liver with time.

B. Wilsons disease ; disturbance in the metabolism and defective

excretion of cupper in the liver that will accumulate in it leading to

cirrhosis .

C. 1-antitrypsin deficiency .


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8. Non alcoholic liver disease (NASH non alcoholic steatohepatitis) ; in which there is fat deposition in the liver leading

to liver cirrhosis, deterioration in the liver functions and it

might cause hepatocelluar carcinoma.

NASH occurs in what type of people ?

1. In patients who are obese especially who are having centralobesity ; patients who have just tummy ) ( they are more

liable for NASH .

2. Diabetics patients3.Dyslipidemia

9. Cryptogenic liver cirrhosis;means we dont know the cause ofliver cirrhosis.

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Pathogenesis of the features of liver cirrhosis- We can divide cirrhotic symptoms according to what caused them into two

main categories :

1.Portal hypertension :Elevation of portal vein pressure to more than 10 mmHgdue to anatomic or functional obstruction to blood flow in

the portal venous system .


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portal hypertention can be Classified into: (its not important to knowthem) :

1.Presinusoidal: portal vein thrombosis

2. Sinusoidal: cirrhosis3. Postsinusoidal: Budd chiari syndrome, veno-oclussive

disease

Consequences :1.Esophageal varices2.Splenomegaly and hypersplenism;

-Splenomegaly : when the spleen enlarges, it will be aggressiveagainst all types of blood components. So , insteadof removing old

blood cells , it will destroy all RBCs , WBCs and platelets whatever their

state is . as a result , increment in the destruction of blood components

leading to anemia , leucopenia , thrombocytopenia .

- hypersplenism : hyper-functioning spleen.

- portal vein is formed by union between splenic vein and

mesenteric vein then it enters into the liver ; so when

there is cirrhosis in the liver which causes fibrosis and

obstruction of the radicals of the portal vein ) ( inside

the liver that leads to back pressure and congestion in theportal vein and this will be reflected on the splenic and

mesenteric veins .


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3.Ascites4.Hepatic encephalopathy

2.Liver cell dysfunction:- Manifestations:FatigueLow grade feverFetor hepaticus: Destroyed apple like smell , this comes from

the toxins which is not detoxified by the liver.

Loss of muscle massand subcutaneous fat; thin patients.JaundiceCoagulopathy; deficiency in coagulation factors , you know that

all the coagulation factors except factor 8 are synthesized in the liver

so when there is a disease in the liver there will be deficiency in

these factors which may lead to bleeding .

Low albumin ; albumin is synthesized in the liver and anydeficiency in it will lead to:

1. effect the healing of the tissue2. abdominal ascites3. edema of the lower limps

Cardiovascular changes: Hyperdynamic state due to shunts and vasodilators ; tachycardia Cardiac dysfunction

ASCITES


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Skin changes: palmar erythema, spider nevi, leuconychia (whitenails)

Endocrine changes ; estrogen is mainly metabolized by the liverand if it is in excess amount this may lead to :

In males: infertility, feminization, decreased potency, testicularatrophy, decreased libido

In females: infertility, amenorrhea

Metabolic changes: impaired glucose tolerance, hypoglycemiaBone changes: Osteoporosis and the patient may lose his teethPulmonary changes: infections, effusion, pulmonary

Hypertension.

AscitesHepatic encephalopathy

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palmar erythema

spider nevi

leuconychia


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Investigations in liver cirrhosisBiopsy: is the gold standard for diagnosis but we rarely take a

biopsy especially if the patient has disturbances in the coagulationsystem.

Lab abnormalities:1. Mild to moderate rise in AST and ALT .2. Bilirubin and alkaline phosphatase may be mildly elevated3. Low albumin4.Prolonged PT (prothrombin time): it is the main investigation that

reflects the synthetic function of the liver .

Investigations to find the cause of cirrhosis ; if youdiscover the cause of this cirrhosis and treat it then the

process of cirrhosis starts to stop and even to reverse, so it

is essential to find the cause .

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Clinical picture :Compensated cirrhosis

Decompensated cirrhosis

Cirrhotic patients may develop

hepatocellular carcinoma (HCC)


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- Usually most of the conditions of the liver starts with acute

hepatitis after that the patient either will be cured or will go into a

process called chronic hepatitis , this chronic hepatitis may still as

a mild disease or will go into a severe condition which cause livercirrhosis .

- At this stage the patient is still asymptomatic until

Decompensated cirrhosis starts ; the signs and features of

liver cirrhosis start to appear , and the patient usually

deteriorates rapidly at this stage and the condition will be

fatal.

- In Some types of liver cirrhosis , the patient deteriorates rapidly that

within two years he will die. However in other patients may take ten years

and that is controlled by several factors like the main underlying cause of

liver cirrhosis.

So the main features of Compensated liver cirrhosis :-- Usually asymptomatic- Fatigue is the commonest symptom- signs of chronic liver disease may be present: spider nevi, palmarerythema, nail changes, gynecomastia, testicular atrophy,

hepatosplenomegaly

the main features of Decompensated cirrhosis :-

So , Acute hepatitis >> chronic hepatitis >>

compensated liver cirrhosis (asymptomatic) >>

decom ensated cirrhosis >> death


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- Jaundice- Bleeding esophageal varices- Ascites- Hepatic encephalopathy

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Esophageal varices :- Esophageal varices is one of the worst complications that can occur due to

liver cirrhosis . it develops due to prevention of blood from going to thesystemic circulation resulting in portal hypertension. As a result, the blood is

going to find an exit other than liver to pass into the systemic circulation by

searching upon the nearby veins(collaterals) , it increases the pressure in

collaterals(ansatomotic channels between portal and systemic) . the usual

location of those collaterals is present in lower esophagus and occasionally

in gastric fundus . a large amount of blood will enter these small blood

vessels and this will lead to congestion in these vessels and also may rupture

at any time leading to massive severe bleeding.

To sum up :Obstruction in portal circulation >> blood try to find another exit to

enter the systemic circulation (in the lower end of esophagus)>> there is

no enough blood vessels >> new blood vessels formed >> a lot of

congestion and pressure will be on these vessels >> they may at any

time rupture >> lead to severe massive bleeding .

Jaundice


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- Treatment of esophageal varices :

1.Resuscitation and blood transfusion as needed2.Use of somatostatin or octreotide3.Variceal band ligation (a way to stop bleeding )4.Sclerotherapy injection ; using sclerosing agent that will mimic

fibrosis in that area.

5.B-blockers6.TIPS ; a technique that provides an exit for the portal circulation

into the systemic through routs other than collaterals . by this

technique we put a stent in the liver between the systemic and

portal circulations .7.Surgical shunt operations ; we dont prefer it because it is very

dangerous .

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Ascites

Definition :- It is an accumulation of fluid in the peritoneal cavity of the abdomen

distending it forwards.

Etiology:1. sinusoidal hypertension2. sodium retention3. Hypoalbuminemia4. Lymphatic exudation

Treatment:


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1. Sodium restriction and bed rest2. Spironolactone3. Loop diuretics4. Albumin infusion5. Large volume paracentesis; removal of fluids from the abdomen6. TIPS7. Peritoneovenous shunts8. Liver transplantation(best treatment)

Hepatorenal syndrome (HRS):

- it is the development of renal failure despite normality of structure.- fatal condition that requires a patient to be cirrhotic and ascetic .- Kidneys are histologically normal .- Carries very poor prognosis .

Hepatic encephalopathy (HE):

-It is the worst complication of liver

cirrhosis.

-it is a neuropsychiatric

syndrome in patients with advanced

liver disease due to toxins.

ammonia.ishere in this syndromeThe main toxic we are talking about it-

- Ammonia accumulates in the circulation of cirrhotic patients that goes to the

brain making this syndrome; means when there is a disease in the liver , the

ammonia will not be cleared so it will accumulate and effect the function of the

brain.

Features :-

Normally , ammonia is absorbed from

intestine where there are bacteria acting

on ingested proteins to produce it before

absorbed . then , it accumulates in the

circulation in large amounts. When goes

to the liver , it(ammonia) is converted into

urea which is easy to be cleared by the

kidneys


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1. Deterioration in level of consciousness

2. Behavioral and psychiatric changes

3. Lack of concentration

4. Sleep disturbances

5. Flapping tremors

Precipitating factors for HE :Factors that increase the incidence of HE1.Gastrointestinal bleeding2.Infection3.Narcotics and sedative drugs4.Surgery5.Constipation6.Hypokalemia7.High protein diet8.Biliary diseases

Treatment :- Identify and treat underlying cause.

- Lactulose therapy: the main treatment ; lactulose could kill the bacteria

that produce ammonia by lowering the ph in the intestine.

- Antibiotics: Neomycin, metronidazole, rifaximin

- Drugs that metabolize ammonia:

To hippuric acid: sodium benzoate To glutamine: L-aspartate, L-ornithine (LOLA)

- Extracorporeal albumin dialysis.

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Hematological disturbances in liver cirrhosisi. Anemia:

1.Bleeding2.Folate deficiency3.Hemolytic anemia4.Hypersplenism

ii. Leucopenia due to hypersplenism

iii. Thrombocytopenia due to cirrhosis and hypersplenismiv. Defective coagulation with prolonged prothrombin time and INR

Screening for Hepatocellular carcinoma (HCC) :- Cirrhotic patients are at increased risk for HCC especially: Hepatitis B and C Alcoholic cirrhosis Genetic hemochromatosis Primary biliary cirrhosis

How we can detect HCC?

1.serum alpha-fetoprotein (AFP) testing ; usually the level ofAFP is increased in cirrhotic patients.

2.ultrasonography______________________________________________________________________________


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Liver transplantation :- For patients with advanced decompensated liver cirrhosis.-

Either from living donor(take half of the liver) or fromcadaver(dead donor) .

- 5-year-survival after transplantation is 80%

Significance of liver cirrhosis to dentists:

Risk to patients with cirrhosis:- Increased incidence of infection

- Decreased wound healing

- Increased bleeding

- May precipitate hepatic encephalopathy

- Defective teeth and caries

So you should deal correctly with those patients.Risk to dentist:

- Increased risk of infection with HBV (hepatitis B virus) or HCV

if the patient is having any of them.

So always try to protect yourself by wearing gloves , sterilize all theinstruments after use .


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Past years questions about this lecture ^_^

1)if a patient with liver cirrhosis come to your dental clinic , what is thebest test that should done before any dental treatment ?

a. PT (INR)b. ALT . ASTc. Biopsy

2)All of the following are risk factors for liver cirrhosis expect :a. Hepatitis Bb. Hepatitis Ac. Hepatitis Cd. Hemachromatosis

3)Which of the following is not a complication of liver cirrhosis ?a. Esophageal varicesb. Ascitisc. Hepatorenal syndromed. Caries

4)Which of the following is not a treatment for esophageal varices?a. blood transfusionb. Sclerotherapy injectionc. Variceal band ligationd. Loop diuretics

May protection from GOD be upon all of you .. excuse us if there is any

mistake ..

Done by : Rasha Al-Shboul & Rawan shatnawi

Documents

Lec 9 Part2 Liver Cirrhosis