CirrhosisHarindu Udapitiya,

Temporary Lecturer,

Division of Pharmacology.

Overveiw1. What is cirrhosis

2. Types

3. Etiology

4. Clinical presentation

5. Investigations

6. Complications

7. Management

1.What is Cirrhosis

• Cirrhosis is a consequence of chronic liver disease, characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules leading to loss of liver function and disruption of the liver architecture.

2.Types of cirrhosis1.Micronodular cirrhosis.

• Regenerating nodules are usually <3 mm in size and the liver is involved uniformly.

• This type is often caused by ongoing alcohol damage or biliary tract disease

• 2. Macronodular Cirrhosis

• The nodules are of variable Size and normal acini may be seen within the larger nodules.

• This type is often seen following chronic viral hepatitis

3. Etiology

1. Drugs and toxins

Alcohol, methotrexate, isoniazid, methyldopa

2. infections

Hepatitis B and C , Schistosoma japonicum

3. autoimmune

PBC, autoimmune hepatitis, PSC

4. metabolic

Wilson’s disease, haemochromatosis, alpha 1 antitrypsin, porphyria

5. Biliary obstruction

Cystic fibrosis, atresia, strictures, gall stones

6. vascular

Chronic right heart failure, Budd Chiarisyndrome

7. miscellaneous

Sarcoidosis, intestinal by- pass surgery for obesity

8. unknown

cryptogenic

• Alcoholic liver disease 60-70%

• Viral hepatitis 10%

• Biliary disease 5-10%

• Primary hemochromatosis 5%

• Cryptogenic cirrhosis 10-15%

• Wilson’s, alpha 1AT def rare

4. Clinical presentation

Symptoms1. Non specific symptoms-

– Lethargy

– Malaise

– Abd pain

– loss of appetite

2. Symptoms due to elevated bilirubin-

– Yellowish discoloration of eyes

– Pruritus

3. Symptoms due to liver failure-

– Leg edema

– Abdominal distension

– Loss of hair

4. Symptoms due to complications

– Haemoptysis-UGI bleeding

– Altered behavior-HE

– Worsening abd pain-SBP

Signs

• Eyes and Face

1. Icterus

2. Cyanosis

3. Parotid enlargement

• Hands

1. Clubbing

2. Leukonychia

3. Dupuytren’s contraction

4. Palmar erythema

5. Spider naevi

6. Scratch marks

7. Pigmentation

• Chest

1. Los of axillary hair

2. Spider naevi

3. Gynaecomastia

• Abdomen

1. Hepatomegally

2. Splenomegally

3. Ascites

4. Caput medusae

• Legs

1. Oedema

2. Loss of hair on the shins

• Genitalia

1. Testiculat atrophy

4. Investigations

• 1. Investigations for diagnosis

• 2. Investigations for etiology

• 3. Investigations for severity/complication

1. Investigations for diagnosis

1. USS abdomen

2. Liver biopsy

3. CT abdomen

2. Investigations for etiology

1.Viral hepatitis– Hepatitis B and C serology

2.Autoimmune hepatitis– Anti LKM antibody, anti smooth muscle antibody, IgG

3.Alpha 1 antitrypsin deficiency– Alpha 1 antitrypsin level, phenotype testing

4.Wilson’s disease– Reduced serum Cu and Caeruloplasmin; increased 24 hr

Cu excretion5.haemochromatosis

– s. ferritin6.Hepatocellular carcinoma

– Alpha feto protein level– USS

7.Primary billiary cirrhosis-serum IgM level

3. Investigations for severity/complication

1.liver function testsSerum Albumin

Coagulatory profile/PT

Serum billirubin

2.Liver biochemistryAST(SGOT)

ALT(SGPT)

ALP-biliary canaliculi damage

Gamma GT-hepatobilliary damage

3.Plt count-alcoholic thrombocytopaenia

4.UGI endoscopy-variceal bleeding

Hepatocellular damage

5.Peritoneal fluid analysis-SBP

6.USS-ascites, portal hypertension

7.Renal function tests(SE,S.cre)-hepatorenalsyndrome

5. Management

1.Supportive Management

2.Treatment for specific etiology

3.Treatment for complications

1.Supportive Management

1.Proper Nutrition

2.Manage bleeding-transfusion, fluid

3.Abdominal paracentesis

4.Tx for itching

5.Regular excersise

2.Treatment for specific etiology

1.Viral-antivirals

2.Alcohol-stop alcohol

3. Wilson's disease-chelation therapy

4.Billiary obstruction-relieve obstruction

5.Vascular-manage HF

3.Treatment for complications

1.Variceal bleeding

2.Hepatic encephalopathy

3.Hepatorenal syndrome

4.Ascites

5.Spontaneous bacterial peritonitis

1.Variceal bleeding

Management1. Initial rescitation

2. Vasopressin

3. Endoscopic band ligation

4. Sclerotherapy

5. Balloon tamponade

6. TIPSS

7. Proponalol

2.Hepatic encephalopathy

Risk factors1. GIT bleeding

2. Infection

3. Constipation

4. Medication-opiates, antidepressants

5. Dietary protein

6. Renal failure

7. Portosystemic shunts

Management1. Low protein diet

2. Lactulose

3. Antibiotis-neomycin, metranidazole

4. LOLA, Zinc

5. Sodium Benzoate

6. General measures

3.Hepatorenal Syndrome

Management

1. Liver transplantation

2. Agonists of vasopressin-ornipressin and terlipressin

3. Dopamine

4. Renal vasoconstrictor antagonists-Saralasin

5. Surgical shunts

4.Ascites

Management1. Sodium restriction

2. Diuretics-aldosteron, Frusemide

3. Terapeutic paracentesis

4. TIPSS

5.Spontaneous bacterial peritonitis

Management• Start Tx with cefotaxime 2g 8 hrly

• Change antibiotic according to culture report

6. Prognosis

Prognosis depends on the Child-Pugh score

Summery1. Pathology

2. Etiology

3. Clinical presentation

4. Investigations

5. Complications

6. Management

7. Prognosis