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

•  Chronic Liver Disease

Common

• chronic alcohol consumption
• post-viral
  • hepatitis B +/- D
  • hepatitis C
  • ?other viruses
• Chronic Autoimmune Hepatitis
• Primary Biliary Cirrhosis
• Hereditary Haemochromatosis
• Idiopathic
• Drugs
  • methotrexate

Others

• inflammatory
  • Primary Sclerosing Cholangitis
• Vascular
  • Hepatic venous congestion
  • Budd-Chiari syndrome
  • Veno-occlusive disease
• Neoplastic
• Metabolic
  • Wilson's Disease
  • Galactosaemia
  • Glycogen storage disease
• Intestinal bypass operations for obesity
• Drugs
• Congenital / Genetic
  • alpha₁-antrypsin deficiency
  • Cystic Fibrosis
  • Indian Childhood Cirrhosis

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

• Portal Hypertension
  • gastrointestinal Haemorrhage
  • Portosystemic Encephalopathy
• Hepatocellular failure
  • jaundice
  • coagulopathy
  • encephalopathy
  • Hepatorenal Sydrome
• Ascites
  • Spontaneous Bacterial Peritonitis
• Hepatocellular Carcinoma

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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