Liver Cirrhosis

Assist. Prof. Mona Arafa

Tropical Medicine Department

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

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

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

Normal Liver

Cirrhosis

Normal Liver Histology

CV

PT

Cirrhosis

Fibrosis

Regenerating Nodule

Classification of Cirrhosis

◘ WHO divided cirrhosis into 3 categories based on morphological characteristics of the hepatic nodules

1. Micronodular

2. Macronodular

3. Mixed

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

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.

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.

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.

“White Nails”

Palmar Erythema

Clinical Features of Cirrhosis

Prominent abdominal veins.

Complications

Portal hypertension Ascites Varices

Coagulation defects Hepatic encephalopathy Hepatocellular carcinoma Hepatorenal syndrome

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

Diagnosis of cirrhosis Imaging modalities

*Abdominal ultrasound.

*Computed tomography (CT).

*Magnetic resonance imaging (MRI).

*Fibroscan Esophagogastroduodenoscopy (EGD). Liver Biopsy.

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

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

Management

Specific treatment*Antiviral in HBV-cirrhosis*Corticosteroids in AIH*Phlebotomy in hemochromatosis

Treatment of complications Screening for HCC Liver transplantation

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.

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(

Post hepatic causes:

*Chronic right sided heart failure*TR

*Obstructing lesions of hepatic viens and I.V.C )Budd-chiari syndrome (

Management of complications Varices

May be esophageal, gastric, colo-rectal Diagnosis

*History : Hematemesis, melena

*Physical examination

*Ultrasound abdomen

*Endoscopy

Esophageal Varices

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)

EST & EBL

Management of complications Varices

Prevention

*Endoscopy for every cirrhotic patient at diagnosis and periodically

*Treat underlying disease

*Beta blockers

*Endoscopic Band Ligation (EBL)

Ascites

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

Paracentesis

Hepatic encephalopathy

Neuropsychiatric abnormalities secondary to liver disease

BRAIN

LIVER

Toxic N2 metabolites

From Intestines

Porta systemic shunts

Pathogenesis of Hepatic Encephalopathy

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

Thank You