Cirrhosis

This presentation includes basic important facts about cirrhosis in clinical point of view.This might helpful in clinical management of patient suspecting cirrhosis.

1. Cirrhosis Harindu Udapitiya , Temporary Lecturer, Division of Pharmacology .

2. Overveiw What is cirrhosis Types Etiology Clinical presentation Investigations Complications Management

3. 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.

4. 2.Types of cirrhosis 1.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

5. 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

6. 3. E tiology

7. 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

8. 5. Biliary obstruction Cystic fibrosis, atresia, strictures, gall stones 6. vascular Chronic right heart failure , Budd Chiari syndrome 7. miscellaneous Sarcoidosis , intestinal by- pass surgery for obesity 8. unknown cryptogenic

9. 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

10. 4. Clinical presentation

11. Symptoms 1. 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

12. 4. Symptoms due to complications Haemoptysis -UGI bleeding Altered behavior-HE Worsening abd pain-SBP

13. Signs Eyes and Face Icterus Cyanosis Parotid enlargement

14. Hands Clubbing Leukonychia Dupuytren’s contraction Palmar erythema Spider naevi Scratch marks Pigmentation

15. Chest Los of axillary hair Spider naevi Gynaecomastia

16. Abdomen Hepatomegally Splenomegally Ascites Caput medusae

17. Legs Oedema Loss of hair on the shins Genitalia Testiculat atrophy

18. 4. Investigations 1. Investigations for diagnosis 2. Investigations for etiology 3. Investigations for severity/complication

19. 1. Investigations for diagnosis USS abdomen Liver biopsy CT abdomen

20. 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 excretion 5.haemochromatosis s. ferritin 6.Hepatocellular carcinoma Alpha feto protein level USS 7.Primary billiary cirrhosis -serum IgM level

21. 3. Investigations for severity/complication 1.liver function tests Serum Albumin Coagulatory profile/PT Serum billirubin 2.Liver biochemistry AST(SGOT) ALT(SGPT) ALP-biliary canaliculi damage Gamma GT- hepatobilliary damage 3.Plt count-alcoholic thrombocytopaenia 4.UGI endoscopy- variceal bleeding Hepatocellular damage

22. 5.Peritoneal fluid analysis-SBP 6.USS-ascites, portal hypertension 7.Renal function tests( SE,S.cre )- hepatorenal syndrome

23. 5. Management 1.Supportive Management 2.Treatment for specific etiology 3.Treatment for complications

24. 1.Supportive Management 1.Proper Nutrition 2.Manage bleeding-transfusion, fluid 3.Abdominal paracentesis 4.Tx for itching 5.Regular excersise

25. 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

26. 3.Treatment for complications 1.Variceal bleeding 2.Hepatic encephalopathy 3.Hepatorenal syndrome 4.Ascites 5.Spontaneous bacterial peritonitis

27. 1.Variceal bleeding

28. Management Initial rescitation Vasopressin Endoscopic band ligation Sclerotherapy Balloon tamponade TIPSS Proponalol

29. 2.Hepatic encephalopathy

30. Risk factors GIT bleeding Infection Constipation Medication-opiates, antidepressants Dietary protein Renal failure Portosystemic shunts

31. Management Low protein diet Lactulose Antibiotis -neomycin, metranidazole LOLA, Zinc Sodium Benzoate General measures

32. 3.Hepatorenal Syndrome

33. Management 1. Liver transplantation 2 . Agonists of vasopressin- ornipressin and terlipressin 3. Dopamine 4. Renal vasoconstrictor antagonists- Saralasin 5. Surgical shunts

34. 4.Ascites

35. Management Sodium restriction Diuretics- aldosteron , Frusemide Terapeutic paracentesis TIPSS

36. 5.Spontaneous bacterial peritonitis

37. Management Start Tx with cefotaxime 2g 8 hrly Change antibiotic according to culture report

38. 6. Prognosis Prognosis depends on the Child-Pugh score

39. Summery Pathology Etiology Clinical presentation Investigations Complications Management Prognosis