9 Liver Cirrhosis

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Liver CirrhosisProfessor Niazy Abu Farsakh


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Liver cirrhosis

Chronic progressive liver disease leading

to :

Necroinflammatory reaction

Fibrosis

Loss of the lobular and vascular architecture

of liver lobules

Regenerating nodules


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Causes of liver cirrhosis

Viral hepatitis: B and C

Alcohol

Biliary diseases: primary or secondary

Autoimmune hepatitisVascular causes: CHF, Budd-Chiari syndrome,Veno-occlusive disease

Drugs and toxins

Hereditary and metabolic: hemochromatosis,Wilsons disease, 1-antitrypsin deficiency

Non alcoholic liver disease (NASH)

Cryptogenic liver cirrhosis


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Pathogenesis of the features of

liver cirrhosis

Due to:

Portal hypertension

Liver cell dysfunction


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Portal circulation


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Portal hypertension

Elevation of portal vein pressure to more than10 mmHgdue to anatomic or functional obstruction to blood flow inthe portal venous system

Classified into: Presinusoidal: portal vein thrombosis Sinusoidal: cirrhosis

Postsinusoidal: Budd chiari syndrome, veno-oclussive disease

Consequences: Esophageal varices

Splenomegaly and hypersplenism

Ascites

Hepatic encephalopathy


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Manifestations of liver cell

dysfunctionFatigue

Low grade fever

Fetor hepaticus

Loss of muscle mass and subcutaneous fatJaundice

Coagulopathy

Low albumin

Cardiovascular changes: Hyperdynamic state due to shunts and vasodilators

Cardiac dysfunction


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Manifestations of liver cell

dysfunctionSkin changes: palmar erythema, spider nevi,leuconychia

Endocrine changes: In males: infertility, feminization, decreased potency, testicular

atrophy, decreased libido

In females: infertility, amenorrhea

Metabolic changes: impaired glucose tolerance,hypoglycemia

Bone changes: Osteoporosis

Pulmonary changes: infections, effusion, pulmonaryhypertension, impaired CO diffusion, cyanosis

Ascites

Hepatic encephalopathy


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Investigations in liver cirrhosis

Biopsy is the gold standard for diagnosis

Lab abnormalities:

Mild to moderate rise in AST and ALT Bilirubin and alkaline phosphatase may be

mildly elevated

Low albumin

Prolonged PT

Investigations to find the cause of cirrhosis


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Clinical picture

Compensated cirrhosis

Decompensated cirrhosis

Cirrhotic patients may develophepatocellular carcinoma (HCC)


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Compensated liver cirrhosis

Usually asymptomatic

Fatigue is the commonest symptom

Signs of chronic liver disease may bepresent: spider nevi, palmar erythema, nail

changes, gynecomastia, testicular atrophy,

hepatosplenomegaly


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Decompensated cirrhosis

Jaundice

Bleeding esophageal varices

AscitesHepatic encephalopathy


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Esophageal varices

Due to portal hypertension resulting in

increased collateral circulation between

high pressure portal venous system and

the low pressure systemic venous system.

Present in lower esophagus, occasionally

in gastric fundus.

May rupture and lead to severe recurrent

bleeding which is frequently fatal


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Esophageal varices


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Treatment of esophageal varices

Resuscitation and blood transfusion asneeded

Use of somatostatin or octreotide

Variceal band ligation

Sclerotherapy

B-blockers

TIPS

Surgical shunt operations


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Ascites

Defined as fluid in the peritoneal cavity

May occur in other conditions: CHF,nephrotic syndrome

Mechanism of ascites in liver cirrhosis: sinusoidal hypertension

sodium retention (secondary to systemic and

splanchnic vasodilatation) Hypoalbuminemia

Lymphatic exudation


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Treatment of ascites:

Sodium restriction and bed rest

Spironolactone

Loop diuretics

Albumin infusion

Large volume paracentesis

TIPS

Peritoneovenous shunts

Liver transplantation


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Hepatorenal syndrome (HRS)

Development of renal failure in patients

with refractory ascites

Due to decreased renal perfusion

Kidneys are histologically normal

Ascites and hyponatremia usually present

Carries very poor prognosis


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Hepatic encephalopathy (HE)

Neuropsychiatric syndrome in patients withadvanced liver disease.

Due to the toxic effect of substances normallymetabolized by the liver on the brain, mainly

ammonia.Features: Deterioration in level of consciousness

Behavioral and psychiatric changes

Lack of concentration Sleep disturbances

Flapping tremors


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Precipitating factors for HE

Gastrointestinal bleeding

Infection

Narcotics and sedative drugs

Surgery

Constipation

Hypokalemia

High protein diet

Biliary diseases


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Treatment of HE

Identify and treat underlying cause.Lactulose therapy:

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

cirrhosis

Anemia: Bleeding

Folate deficiency

Hemolytic anemia

Hypersplenism

Leucopenia due to hypersplenism

Thrombocytopenia due to cirrhosis and

hypersplenismDefective coagulation with prolongedprothrombin time and INR


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Screening for Hepatocellular

carcinoma (HCC)

Cirrhotic patients are at increased risk forHCC especially:

Hepatitis B and C

Alcoholic cirrhosis Genetic hemochromatosis

Primary biliary cirrhosis

Screening is by: serum alpha-fetoprotein (AFP) testing

ultrasonography


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Liver transplantation

For patients with advanced

decompensated liver cirrhosis.

Either from living donor or from cadaver

5-year-survival after transplantation is 80%


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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

Risk to dentist: Increased risk of infection with HBV or HCV if

the patient is having any of them

9 Liver Cirrhosis

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