Cirrhosis

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Cirrhosis


  • "diffuse process characterised by fibrosis and a conversion of normal architecture to structurally abnormal nodules"
  • irreversible change
    • control of primary disease may control progression
  • slowly evolves
    • constant stimulation by aetiological agent
    • regeneration and repair

Causes

Common

Others

Pathogenesis

  • chronic injury leads to
    • inflammation leads to
    • necrosis leads to
    • fibrosis
  • liver architecture diffusely abnormal
  • altered blood flow leads to
    • portal hypertension
    • impaired liver cell function

Pathology

  • regenerating nodules separated by fibrous septa
  • loss of normal lobular architecture
  • micronodular
    • regenerating nodules <3mm
    • liver involved uniformly
    • often caused by ongoing alcohol / biliary tract disease
  • macronodular
    • nodules of varying size (>3mm)
    • some normal acini present
    • often seen following previous hepatitis (HBV)
  • mixed micronodular / macronodular

Clinical Features

  • of Chronic Liver Disease
  • anaemia
  • portal hypertension
  • defective synthesis of clotting factors
  • thrombocytopenia
  • malnutrition
  • electrolyte disturbances
    • hyponatraemia
  • defective energy metabolism
  • abnormal drug metabolism and distribution
  • ascites

Investigations

of severity

  • U&E
    • reduced sodium indicates severe disease or over-diuresis
  • serum albumin
    • poor outlook if <25g / L
  • Prothrombin time
    • lengthened equates to severity of disease
  • Liver biochemistry
    • may be normal
    • increased ALP
    • increases AST/ALT

of Type

  • viral markers
  • serum autoantibodies
  • serum immunoglobulin
  • miscellaneous
    • serum copper
    • serum alpha1-antitrypsin
    • Serum iron, TIBC

Imaging

  • USS
  • CT scan
  • Barium swallow
  • Scintiscanning
  • Endoscopy

Liver Biopsy

Management

  • correct any underlying disorder
  • avoid alcohol
    • unless cause of cirrhosis then small amounts okay
  • manage complications

Complications

Prognosis

  • 5 years survival ~50%
  • surgery carries 30% risk
    • 10% Child's A
    • 76% Child's C

Indicators (poor prognosis)

  • albumin <25g/L
  • sodium <120mmol/L
  • Prothrombin Time /INR
  • Persistent jaundice
  • Failure of response to therapy
  • Ascites
  • Haemorrhage from varices
  • Portosystemic Encephalopathy
  • Small liver
  • Persistent Hypotension
  • Aetiology
    • e.g. continuing alcohol if cause

Classification

  • Child's
    • A to C
    • based on
      • jaundice
      • ascites
      • encephalopathy
      • level of serum albumin
    • Grade C
      • albumin <30g/L
      • bilirubin >50mmol/L
      • ascites
 

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