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COMPLICATIONS OF CIRRHOSIS
Arjmand Mufti
UTSW
Outline
• Portal hypertension
• Ascites
• Hepatic encephalopathy
• Hepatorenal syndrome
• Hypoalbuminemia and coagulopathy
• Hepatocellular carcinoma
• Prognostic Tools
CirrhosisNormal
Nodules
Irregular surface
Cirrhosis
Definition• Diffuse fibrosis following hepatocyte
destruction and nodular regeneration• Multiple causes
– All may lead to cirrhosis
• Asymptomatic (compensated)• Symptomatic (decompensated)
– portal hypertension– hepatic failure
The Natural History of cirrhosis
Decompensation:•Variceal hemorrhage
•Ascites•Encephalopathy
•Jaundice
D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:217-231.
Liver insufficiency
Variceal hemorrhage
Decompensated Cirrhosis
Ascites
Encephalopathy
Jaundice
Portal hypertension SBP
HRS
Compensated Cirrhosis
5- 7%per year
Complications of Cirrhosis Result from Portal Hypertension or Liver Insufficiency
Natural History of Cirrhosis
Stage Definition 1-year mortality
Median Survival
1 Compensated without varices
1% >12 years
2 Compensated with varices 3%
3 Decompensated with ascites without variceal hemorrhage
20% ~2 years
4 Decompensated with/out ascites with variceal hemorrhage
57%
D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:217-231.
Clinical Presentation
• Symptoms– Anorexia– Weight loss– Generalized
weakness
– Easy fatigability
– Nausea
– Vomiting– Diarrhea
• Exam Findings– Spider angiomatas– Palmar erythema– Gynecomastia– Testicular atrophy– Leuconychia– Parotid gland
hypertrophy– Dupuytren’s contractures– Clubbing– Jaundice
Asymptomatic
Portal Hypertension
Arroyo, V. & Fernández, J. Nat. Rev. Nephrol. 2011
Mechanisms Leading to Circulatory & Renal Dysfunction in Cirrhosis
6040 80 100 120 140 1600
40
60
80
20
200
100
Months
Probability of survival
All patients with cirrhosis
Decompensated cirrhosis
180
Gines et. al., Hepatology 1987;7:122
Median survival~ 9 years
Median survival~ 9 years
Median survival~ 1.6 years
Median survival~ 1.6 years
Decompensation shortens survival
Venous Anatomy
Cirrhotic Liver
Pressure Measurements
Portal Venous Pressure (PVP)
Normal = 5-10 mm Hg
Hepatic Venous Pressure Gradient (HVPG)
= portal venous pressure - hepatic venous pressure or RA pressure
Normal = 1-5 mm Hg
PORTAL HTN
• HVPG ≥6 mm Hg• HVPG ≥10mm Hg – clinically significant• HVPG ≥12 mmHg, risk of variceal
bleeding and the development of ascites• HVPG >20 mmHg – bleeding unlikely to
respond to conventional therapy
Definition of Portal Hypertension
PathophysiologyPortal Hypertension
• Increased intrahepatic vascular resistance– Fixed component
• Sinusoidal fibrosis• Compression by regenerative nodules
– Functional component• Vasoconstriction
– Deficiency in intrahepatic NO– Enhanced activity of vasoconstrictors
Classification Type Examples
• Prehepatic Portal or splenic vein thrombosis
Presinusoidal Schistosomiasis• Intrahepatic Sinusoidal Cirrhosis
Postsinusoidal Veno-occlusive disease
• Posthepatic Hepatic vein thrombosisConstrictive pericarditis
Varices: Portosystemic Collateral Formation
• Esophageal varices
• Gastric varices
• Intraabdominal varices
• Caput medusa
• Rectal varices
Variceal Bleeding
35-80% 25-40%
50-70%
Survival Death
Rebleed
30-50%
70%
Varices
• Common lethal complication
• ~ 50% of patients with cirrhosis
• More likely to bleed in more decompensated disease– 40% of Child A – 85% of Child C
Practice Guidelines: Am J Gastroenterol. 2007;102:2086-2102
%Patients with
varices
100
60
40
20
0
Overalln=494
Child A
n=346
Child B
n=114
80
Child C
n=34
Large
Medium
Small
Pagliaro et al., In: Portal Hypertension: Pathophysiology and Management, 1994: 72
Prevalence and Size of Esophageal Varices in Patients with Newly-Diagnosed Cirrhosis
LaPlace’s Law
T = wall tension
P1 = intravariceal pressure
P2 = esophageal lumen pressure
r = vessel radius
W = wall thickness
T = (P1-P2) x (r/W)
Variceal Bleed: Risk Factors
• High Gradient• Large esophageal varices• Endoscopic features
– red wale markings– cherry red signs
Varices
• All patients with new dx of cirrhosis should undergo EGD to screen for varices
• High risk for bleeding:– Childs B/C (more
evidence of decompensation)
– Large varices– Red wale markings
Varices
• Primary prophylaxis (never bled)– If no varices: no need for nonselective B
blocker– If small varices: no long term evidence to use B
blocker unless red signs present– If large varices:
• High risk patient (red wale, childs B/C): B blocker (nadolol/ propranolol) or prophylactic banding
• Low risk patients: B blocker
– Titrate B blocker to max tolerated dose
Got one for you…Variceal Bleed
• Blood transfusion: Target Hgb=8• Antibiotics: norfloxacin, IV cipro, ceftriaxone
(probably best)• Vasopressin, telipressin, octreotide, vapreotide x
3-5 days– Splanchnic vasoconstriction, reduced portal flow
• EGD within 12 hours– Banding(almost always) or sclerotherapy (rare)
Variceal Bleed: When Banding Fails
• Balloon Tamponade (Blakemore / Minnesota tube) temporizing measure for up to 24 hours
• TIPS
After the Bleed
• Secondary prophylaxis– All patients who have has a variceal bleed– Combination of B Blocker and serial banding– Continue banding (usually outpt) until varices
are eradicated
Take Home: Varices
• All patients with cirrhosis should be screened with EGD
• Primary prophylaxis– Large varices / decompensated patients : usually
nonselective B blocker– Banding and “sicker” patients
• Variceal bleed: abx, octreotide, Hgb 8,scope with banding– Blakemore/TIPS when in trouble
• Secondary prophylaxis– Combination B blocker / banding to eradication
Ascites
ASCITES
Definition
• Fluid within the peritoneal cavity
• Occurs in 50-60% of patients with cirrhosis over 10-15 years
• Mixture of liver and intestinal lymph
Cirrhosis Heart failure
Peritoneal tuberculosis
Cirrhosis is the Most Common Cause of Ascites
Others•Pancreatic •Budd-Chiari syndrome•Nephrogenic ascites
Peritoneal malignancy
CIRRHOSIS IS THE MOST COMMON CAUSE OF ASCITES
85%
33
Ultrasound
Pathophysiology
Elevated Hydrostatic Pressure
•Cirrhosis•Congestive heart failure•Constrictive pericarditis•Hepatic outflow block
Decreased Oncotic Pressure
•Nephrotic syndrome•Protein-losing enteropathy•Malnutrition•Cirrhosis
Peritoneal Fluid Production > Resorption
•Infections (bacterial, tuberculosis, fungal)•Neoplasms
Hepatic Sinusoid• Unlike other capillaries, normal hepatic sinusoids
lack a basement membrane. • The sinusoidal endothelial cells themselves
contain large fenestrae (200-400 nm in diameter)
• These two features make the normal hepatic sinusoid very permeable with movement of fluid depending mostly on hydrostatic pressure
• Normal portal sinusoid pressure is 3-4 mmHg
36
THE PERMEABILITY OF THE HEPATIC SINUSOID VARIES IN HEALTH AND DISEASE
In cirrhosis, the hepatic sinusoid is LESS leaky
The Permeability of the Hepatic Sinusoid Varies in Health and Disease
Hepatocytes
The normal sinusoid is “leaky”
Sinusoid
Sinusoid
fibrous tissue deposition “capillarization” of
sinusoid
no basement membrane
37
Clinical Presentation
• Abdominal distention
• Bulging flanks
• Shifting dullness
• Fluid wave
• Fluid detected on US or CT scan
Total Protein
(SAAG = serum albumin - ascitic albumin)
≥1.1 <1.1
<2.5 -Cirrhosis-Acute Liver Failure-Alcoholic Hepatitis-Massive Hepatic Mets
-Nephrotic syndrome-Myxedema
≥2.5 -CHF-Constrictive Pericarditis-Budd-Chiari-Venoocclusive Disease
-Peritoneal Carcinomatosis-TB Peritonitis-Pancreatic Ascites-Chylous Ascites-Serositis 39
Serum-Ascites Albumin Gradient
Treatment of Ascites
• Usually responds to Na restriction and diuretics– When SAAG >1.1
• Dual diuretics:– Furosemide AND Spirololactone
• Single daily dosing (40/ 100)
• Na restriction– <2000mg/day
• Fluid restriction is usually NOT necessary
Patients with Refractory Ascites Have Worse Survival than Patients with Diuretic-Responsive Ascites
Survival probability
1.0
.8
.6
.4
.2
0120 24 4836 60 8472
Refractory ascites
Non refractory ascites
p<0.001
Months
Salerno et al., Am J Gastroenterol 1993; 88:514
In refractory ascites…
• AVOID– ACE inhibitors / angiotensin receptor blockers
• Blood pressure / adverse renal effects
– Propranolol• Blood pressure / circulatory dysfunction during
LVP• Renal function
– Consider risks benefits
– NSAIDS
With Large / Tense ascites
• Therapeutic paracentesis followed by diuretics / Na restriction
• 6-8 g/of albumin per liter of ascites removed
• Midodrine may be helpful– Shown to increase BP, survival benefit
• Consideration of liver transplantation referral
Complications of Ascites
• Hepatorenal syndrome– “The HRS Cocktail”
• Albumin + Octreotide + Midodrine
– In ICU: • Albumin + Norepineprhine
• Hepatic Hydrothorax– NO CHEST TUBE!!– Same as acsites (Na restrict / diuretics)
Spontaneous Bacterial Peritonitis (SBP)
Infectious complications of cirrhosis1. Spontaneous bacterial peritonitis (SBP)2. Urinary tract infection3. Pneumonia4. Bacteremia
SBP 7-25% of hospitalized cirrhotics– In-hospital mortality 20-50%
Recurrence of SBP 30-70%
Borzio M Dig Liver Dis 2001;33(1):41-8Runyon Hepatology 2004
Infecting Agents
Eschericia coli 43%
Klebsiella pneumoniae 8%
Streptococcus pneumoniae 8%
Alpha-hemolytic streptococcus 5%
Group D stretocococcus 8%
Miscellaneous Enterobacteriaceae 3%
Miscellaneous 20%
ASCITES
Spontaneous Bacterial Peritonitis (SBP)
• Tap all patients admitted to hospital or for any reason rub you the wrong way…
• Diagnosis:– Culture NOT needed (but send it anyways)– PMN >250cells/mm3
• Treatment:– 3rd gen cephalpsporin ie cefotaxime 2g q8– Albumin 1.5g/kg day 1 and 1.0 g/kg day 3
• Cr >1, BUN >30, or bili >4
SBP : prevention
• GI bleed and cirrhosis– Ceftriaxone or norflox x 7 days
• If prior episode of SBP, long term prophylaxis– Daily norfloxacin or bactrim
Hepatic Encephalopathy
Definition
• Reversible alteration in the neuropsychiatric function
• Due to shunting of neurotoxic nitrogenous products
• Lack of hepatic detoxification
Hepatic Encephalopathy Pathogenesis
Bacterial actionProtein load
Failure to metabolize
NH3
NH3 Shunting
GABA-BD receptors
Toxins
1 2 3 4
Coma
Somnolence
Confusion
Drowsiness
????
? ?
StagesHE
Adapted from AGA Teaching Slides.
Hepatic Encephalopathy (HE)
• 10-50% of cirrhotics
• 40% survival 1 year after 1st episode
• 15% survival 3 years after 1st episode
• Disturbance in diurnal sleep pattern precedes neurologic signs
Minimal Encephalopathy
• 15-30% have abnormal NCT or abnormal EEG without overt encephalopathy
• Significance unclear– impaired health-related quality of life
(HRQOL) compared to patients with cirrhosis without minimal HE
– impairs driving capacity and poor insight into their driving skills
• Not replicated in real life conditionsMetab Brain Dis 1998 Jun;13(2):159-72
Hepatology 1998 Jul;28(1):45-9
Metab Brain Dis 1995 Sep;10(3):239-48
Kappus et al Clinical Gastroenterology and Hepatology, Volume 10, Issue 11, 2012, 1208 - 1219
Classification of Hepatic Encephalopathy
Management of HE
• Identify / treat precipitating factors
• Empiric treatment – Rifaximin – Lactulose
GI bleedingExcess protein
Sedatives / hypnotics
TIPSDiuretics
Serum K+
Plasma volume
Azotemia
Temp
Infections
Precipitating Factors of HE
Ammonia Levels in HE
• May be correlation of ammonia levels and severity of HE
• Diagnosis and treatment is clinical– Should not change management– No utility in following levels
Treatment of HE
• Lactulose– First line– 2-3 soft BM/ day
• Rifaximin– 550 BID– Reduced ammonia
producing bacteria
Long Term Management of HE
• After initial HE event– Usually on therapy indefinitely or until liver
transplant
– Long term use of lactulose and or rifaximin
• High protein diet is OK (and preferred in cirrhosis)
• Patients with HE should NOT undergo TIPS if possible
Hepatorenal Syndrome
Pathophysiology
• Occurs in setting of cirrhosis and ascites
• Severe renal arterial vasoconstriction
• Compromised glomerular filtration rate
• Normal kidney structure
1.0
0.8
0.6
0.4
0.2
0.0
Su
rviv
al
Type 1 hepatorenal syndrome
Months
Gines et al. NEJM 2004;350:1646-1654.
P<0.001
Creatinine <1.2 mg/dL
Creatinine 1.2-1.5mg/dL
Creatinine >1.5mg/dL
1.0
0.8
0.4
0.2
0.0
1 2 3 4 5
Years
Su
rviv
al
Refractory ascites
Survival in Cirrhosis Based on Level
of Renal Dysfunction
Survival Among Patients With Cirrhosis and HRS
1 2 3 4 500 6
0.6
00
Survival is Decreased with Renal Dysfunction
Setting
•Advanced liver disease: cirrhosis, alcoholic hepatitits, fulminant hepatitis
•Sometimes precipitated by overdiuresis, GI bleed, use of nephrotoxic agents
Clinical Features•Ascites • Oliguria•Hypotension • Jaundice
Course•Typically death within weeks
Hepatorenal Syndrome
Splanchnic/systemic vasodilatation
Intrahepatic resistance
Portal (sinusoidal) hypertension
Activation of neurohumoral systems
Cirrhosis
Effective arterial blood volume
Renal vasoconstriction
HEPATORENAL SYNDROME
Type 1 and Type 2 HRS
• HRS Type 1– Rapidly progressive– Precipitating event frequent, esp SBP– Very short survival
• HRS Type 2– Slow onset of moderate renal insufficiency– Poor response to diuretics (refractory ascites)– Longer survival
0 2 4 6 8 1210
Months
1
0.2
0.4
0.6
0.8
Survival probability
0
Type 2
p = 0.001
Gines et al., Lancet 2003; 362:1819
Type 1
Prognosis in Type 1 and 2 HRS
Precipitants of Type 1 HRS
• Infection– Spontaneous bacterial peritonitis (SBP)– Urinary tract infection– Cellulitis
• Gastrointestinal hemorrhage• NSAID use• Large volume paracentesis without albumin• Adrenal insufficiency
Salerno et al. Gut 2007
HRS Diagnostic Criteria
1. Cirrhosis with ascites
2. Serum CR >1.5 mg/dL
3. No improvement in serum CR after at least 2 days of diuretic withdrawal & volume expansion with albumin (max 100g/day)
4. Absence of shock
5. No current or recent nephrotoxic drugs
6. Absence of parenchymal kidney disease
Clinical Characteristics of HRSAscites
Advanced liver disease
Low mean arterial pressure (median 74 mmHg)
Low serum Na (median 127 mEq/L)
Low urinary output
Do not rely on urine Na or urine sediment to differentiate HRS from ATN
Garcia-Tsao et al. Hepatology 2008
Prevention of AKI in cirrhotics Careful use of diuretics & lactulose Albumin after large volume paracentesis Avoid NSAIDs & aminoglycosides Albumin & antibiotics for treatment of SBP Primary prophylaxis of SBP with
antibiotics Antibiotics for 5-7 days at time of GI bleed
Precipitants
• Treatment principles• Treat the underlying precipitant promptly
• More quickly addressed the more likely to have improvement in HRS
• Have a high suspicion for an occult precipitating event in any liver patient who has ARF
• Even with removal of the precipitant, HRS may be irreversible
72
Treatments
• Precipitating events
• Renal vasodilators
• Systemic vasoconstrictors
• TIPS
• Dialysis
• Transplantation
73
Hepatocellular Carcinoma
Hepatocellular Carcinoma
• Seen in cirrhosis– Exception: HBV (can be noncirrhotic)
• Diagnosis by US, CT scan, MRI– Histology is not essential
• Alpha-fetal protein level may be elevated
Hepatocellular Carcinoma (HCC)
• Surveillance– Screen all patients with cirrhosis for HCC
• Up to 8% risk of HCC/year
– Also male HBV carriers >40 and female HBV >50 (even if they don’t have cirrhosis)
• Up to 0.6% risk of HCC/year
• For boards…screen with ultrasound q 6 months– No benefit to shorten interval– No benefit to screen with AFP– In practice many still use cross sectional imaging and
AFP to screen as well
Diagnosis of HCC
• Usually with imaging, histology used less often
• If lesion seen on u/s> 1cm then follow up with CT or MR– If hypervascular lesion that washes out on
portal venous phase then dx with HCC– No bx needed
CT appearance of HCC
Arterial Phase
Arterial Phase Washout
Treatment of HCC
• Resection
• Local-Regional therapy– TACE– RFA– Ethanol ablation
• Liver transpantation
• Systemic– Sorafenib
Treatment of HCC
• Resection– Less commonly used– Noncirrhotic or very well compensated
• Well preserved synthetic function (INR near normal)
• Normal bili• Low portal pressure
– Possibly for noncirrhotic HBV patient..– No role for adjuvant chemotherapy
Treatment of HCC
• Local ablation– Alcohol injection
• Only in smaller tumors
• Not used very often
– Radiofrequency ablation• Better for larger tumors
– May use as a bridge to liver transplantation
Treatment of HCC
• Transarterial Chemoebolization (TACE)– Non curative– Nonsurgical patients
– Large multifocal HCC– No vascular invasion– No extrahepatic spread
Treatment of HCC
• Liver transplantation– Curative approach– Milan Criteria
• 1 tumor <5cm• Up to 3 tumors <3cm• No vascular / extrahepatic spread
– Tumor exception points• MELD=22
Treatment of HCC
• Sorafenib– Last resort– Cannot benefit from resection, transplantation,
ablation or TACE– Multifocal disease with well preserved hepatic
function– SHARP trial median survival 10.7 months vs
7.9 months average survival
Take Home: HCC
• Screen patients with u/s q6 months if they have cirrhosis / older patients with HBV
• Usually radiographic diagnosis– Biopsy rarely needed– Cross sectional imaging look for “arterial
enhancement” and “washout”
• Treatment:– Possibly “curative”: ablation, resection,
transplant– Palliative: TACE, sorafenib
Prognostic Tools
Prognostic Models
• Tools for predicting disease severity and death– Child-Turcotte-Pugh (CTP) score– Model or End-Stage Liver Disease (MELD)
Child-Pugh-Turcotte Classification
1 2 3
Albumin (g/dl) >3.5 2.8-3.5 <2.8
Total bilirubin (mg/dl) <2 2-3 >3
Prothrombin time (INR) <1.7 1.7-2.3 >2.3
Ascites None Medically Uncontrolled
controlled
Encephalopathy (grade) 0 I-II III-IV
Class: A = 5-6 points, B = 7-9 points, C = 10-15 points
MELD Score
• Model for Endstage Liver Disease
• MELD = INR, Creatinine, Bilirubin
• Higher scores (6 to 40) indicate worse prognosis
• MELD >15 would benefit from liver transplant
Conclusions
• The transition from compensated cirrhosis to decompensated cirrhosis carries a significant change in mortality
• Clinical diagnosis is important
• Simultaneous compications may (and usually arise)