Cirrhosis and its complications

This presentation is about common causes of cirrhosis,its complications and management

1. Cirrhosis and Its complications Melaku Yitbarek Internal Medicine unit March,2018

2. Introduction Alcoholic Cirrhosis Cirrhosis Due to Viral Hepatitis Cirrhosis Due to Autoimmune hepatitis and and Nonalcoholic liver disease Biliary Cirrhosis Cardiac Cirrhosis Major Complications of Cirrhosis Lecture Outline

3. Cirrhosis is a condition that is defined histopathologically and has a variety of clinical manifestations and complications, some of which can be life-threatening. Regardless of the cause of cirrhosis, the pathologic features consist of the development of fibrosis to the point that there is architectural distortion with the formation of regenerative nodules. Clinical features of cirrhosis are the result of pathologic changes and represent the severity of the liver disease Portal hypertension is a significant complicating feature of decompensated cirrhosis and is responsible for the development of ascites and bleeding from esophagogastric varices, two complications that signify decompensated cirrhosis Introduction

4. Loss of hepatocellular function results in jaundice, coagulation disorders, and hypoalbuminemia and contributes to the causes of portosystemic encephalopathy. The complications of cirrhosis are basically the same regardless of the etiology Nonetheless, it is useful to classify patients by the cause of their liver disease patients can be divided into broad groups with alcoholic cirrhosis, cirrhosis due to chronic viral hepatitis,Biliary cirrhosis,and other less common causes such as cardiac cirrhosis,cryptogenic cirrhosis, and other miscellaneous causes. Introduction…

5. Introduction…

6. Excessive chronic alcohol use can cause several different types of chronic liver disease, including alcoholic fatty liver, alcoholic hepatitis,and alcoholic cirrhosis Furthermore, use of excessive alcohol can contribute to liver damage in patients with other liver diseases, such as hepatitis C, hemochromatosis, and fatty liver disease related to obesity Alcoholic Cirrhosis

7. Pathogenesis Ethanol is mainly absorbed by the small intestine and, to a lesser degree, through the stomach The majority of ethanol oxidation occurs via ADH to form acetaldehyde, which is a highly reactive molecule that may have multiple effects Intake of ethanol increases intracellular accumulation of triglycerides by increasing fatty acid uptake and by reducing fatty acid oxidation and lipoprotein secretion. Protein synthesis , glycosylation, and secretion are impaired. Oxidative damage to hepatocyte membranes occurs due to the formation of reactive oxygen species Alcoholic…

8. Pathogenesis… With acetaldehyde-mediated hepatocyte damage, certain reactive oxygen species can result in Kupffer cell activation. As a result, profibrogenic cytokines are produced that initiate and perpetuate stellate cell activation, with the resultant production of excess collagen and extracellular matrix Hepatocyte loss occurs, and with increased collagen production and deposition, together with continuing hepatocyte destruction, the liver contracts and shrinks in size. This process generally takes from years to decades to occur and requires repeated insults Alcoholic…

9. Clinical features Patients with alcoholic liver disease can present with nonspecific symptoms such as vague right upper quadrant abdominal pain, fever, nausea and vomiting, diarrhea, anorexia, and malaise Alternatively, they may present with more specific complications of chronic liver disease, including ascites, edema, or upper gastrointestinal (GI) hemorrhage Other clinical manifestations include the development of jaundice or encephalopathy Alcoholic…

10. Clinical… On physical examination, the liver and spleen may be enlarged, with the liver edge being firm and nodular. Other frequent findings include scleral icterus, palmar erythema spider angiomas , parotid gland enlargement, digital clubbing, muscle wasting, or the development of edema and ascites. Men may have decreased body hair and gynecomastia as well as testicular atrophy, which may be a consequence of hormonal abnormalities or a direct toxic effect of alcohol on the testes Alcoholic…

11. Clinical… In women with advanced alcoholic cirrhosis, menstrual irregularities usually occur, and some women may be amenorrheic These changes are often reversible following cessation of alcohol Laboratory tests may be completely normal in patients with early compensated alcoholic cirrhosis. Alternatively, in advanced liver disease, many abnormalities usually are present. Patients may be anemic either from chronic GI blood loss, nutritional deficiencies, or hypersplenism Alcoholic…

12. Clinical… Platelet counts are often reduced early in the disease, reflective of portal hypertension with hypersplenism. Serum total bilirubin can be normal or elevated with advanced disease. Direct bilirubin is frequently mildly elevated in patients with a normal total bilirubin, but the abnormality typically progresses as the disease worsens. Prothrombin times are often prolonged and usually do not respond to administration of parenteral vitamin K Serum alanine and aspartate aminotransferases (ALT, AST) are typically elevated, particularly in patients who continue to drink, with AST levels being higher than ALT levels, usually by a 2:1 ratio. Alcoholic…

13. Diagnosis… Patients who have any of the above-mentioned clinical features, physical examination findings, or laboratory studies should be considered to have alcoholic liver disease The diagnosis, however,requires accurate knowledge that the patient is continuing to use and abuse alcohol Liver biopsy can be helpful to confirm a diagnosis, but generally when patients present with alcoholic hepatitis and are still drinking, liver biopsy is withheld until abstinence has been maintained for at least 6 months to determine residual, nonreversible disease Alcoholic…

14. Treatment Abstinence is the cornerstone of therapy for patients with alcoholic liver disease In addition, patients require good nutrition and long term medical supervision to manage underlying complications that may develop Complications such as the development of ascites and edema, variceal hemorrhage, or portosystemic encephalopathy all require specific management and treatment Glucocorticoids are occasionally used in patients with severe alcoholic hepatitis in the absence of infection Alcoholic…

15. Treatment… Survival has been shown to improve in certain studies. Treatment is restricted to patients with a discriminant function (DF) value of >32. The DF is calculated as the serum total bilirubin plus the difference in the patient’s prothrombin time compared to control (in seconds) multiplied by 4.6. In patients for whom this value is >32, there is improved survival at 28 days with the use of glucocorticoids Alcoholic…

16. Treatment… Other therapies that have been used include oral pentoxifylline,which decreases the production of tumor necrosis factor a (TNF-a) and other proinflammatory cytokines. In contrast to glucocorticoids,with which complications can occur, pentoxifylline is relatively easy to administer and has few, if any, side effects Alcoholic…

17. Of patients exposed to the hepatitis C virus (HCV), approximately 80% develop chronic hepatitis C, and of those, about 20–30% will develop cirrhosis over 20–30 years Progression of liver disease due to chronic hepatitis C is characterized by portal-based fibrosis with bridging fibrosis and nodularity developing, ultimately culminating in the development of cirrhosis Of adult patients exposed to hepatitis B, about 5% develop chronic hepatitis B, and about 20% of those patients will go on to develop cirrhosis Cirrhosis due to Chronic viral hepatitis(B and C)

18. Clinical features and Dx Patients with cirrhosis due to either chronic hepatitis C or B can present with the usual symptoms and signs of chronic liver disease Fatigue, malaise, vague right upper quadrant pain, and laboratory abnormalities are frequent presenting features Diagnosis requires a thorough laboratory evaluation, including quantitative HCV RNA testing and analysis for HCV genotype, or hepatitis B serologies to include HBsAg, anti-HBs, HBeAg (hepatitis B e antigen), anti- HBe, and quantitative HBV DNA levels. Cirrhosis due to chronic…

19. Treatment: Management of complications of cirrhosis revolves around specific therapy for treatment of whatever complications occur (e.g., esophageal variceal hemorrhage, development of ascites and edema, or encephalopathy) In patients with chronic hepatitis B, numerous studies have shown beneficial effects of antiviral therapy Cirrhosis due to…

20. Other causes of posthepatitic cirrhosis include autoimmune hepatitis and cirrhosis due to nonalcoholic steatohepatitis Many patients with autoimmune hepatitis (AIH) present with cirrhosis that is already established. Typically, these patients will not benefit from immunosuppressive therapy with glucocorticoids or azathioprine because the AIH is “burned out.” In this situation, liver biopsy does not show a significant inflammatory infiltrate. Diagnosis in this setting requires positive autoimmune markers such as antinuclear antibody (ANA) or anti-smooth-muscle antibody (ASMA) CIRRHOSIS FROM AUTOIMMUNE HEPATITIS AND NONALCOHOLIC FATTY LIVER DISEASE

21. When patients with AIH present with cirrhosis and active inflammation accompanied by elevated liver enzymes, there can be considerable benefit from the use of immunosuppressive therapy Cirrhosis due to AIH and…

22. Patients with nonalcoholic steatohepatitis are increasingly being found to have progressed to cirrhosis Over the past several years, it has been increasingly recognized that many patients who were thought to have cryptogenic cirrhosis in fact have nonalcoholic steatohepatitis. As their cirrhosis progresses, they become catabolic and then lose the telltale signs of steatosis seen on biopsy. Management of complications of cirrhosis due to either AIH or nonalcoholic steatohepatitis is similar to that for other forms of cirrhosis Cirrhosis due to NASH

23. Biliary cirrhosis has pathologic features that are different from either alcoholic cirrhosis or posthepatitic cirrhosis, yet the manifestations of end-stage liver disease are the same Cholestatic liver disease may result from necroinflammatory lesions, congenital or metabolic processes,or external bile duct compression Thus, two broad categories reflect the anatomic sites of abnormal bile retention: intrahepatic and extrahepatic. The distinction is important for obvious therapeutic reasons. Extrahepatic obstruction may benefit from surgical or endoscopic biliary tract decompression, whereas intrahepatic cholestatic Processes will not improve with such interventions and require a different approach Billiary Cirrhosis

24. The major causes of chronic cholestatic syndromes are primary biliary cirrhosis (PBC), autoimmune cholangitis (AIC), primary sclerosing cholangitis (PSC), and idiopathic adulthood ductopenia. These syndromes are usually clinically distinguished from each other by antibody testing cholangiographic findings, and clinical presentation. However,they all share the histopathologic features of chronic cholestasis, Such as cholate stasis; copper deposition; xanthomatous transformation Of hepatocytes;and irregular, so-called biliary fibrosis Billiary Cirrhosis…

25. Primary billiary cirrhosis(PBC): PBC is seen in about 100–200 individuals per million, with a strong female preponderance and a median age of around 50 years at the time of diagnosis The cause of PBC is unknown Cholestatic features prevail, and biliary cirrhosis is characterized by an elevated bilirubin level and progressive liver failure. Liver transplantation is the treatment of choice for patients with decompensated cirrhosis due to PBC Antimitochondrial antibodies (AMA) are present in about 90% of patients with PBC Billiary…

26. PBC: clinical features Currently, most patients with PBC are diagnosed well before the end-stage manifestations of the disease are present, and, as such, most patients are actually asymptomatic Pruritus is seen in approximately 50% of patients at the time of diagnosis, and it can be debilitating. It might be intermittent and usually is most bothersome in the evening Pruritus that presents prior to the development of jaundice indicates severe disease and a poor prognosis Billiary…

27. PBC:CF… Physical examination can show jaundice and other complications of chronic liver disease, including hepatomegaly, splenomegaly, ascites,and edema. Other features that are unique to PBC include hyperpigmentation,xanthelasma,and xanthomata Laboratory findings in PBC show cholestatic liver enzyme abnormalities with an elevation in γ- glutamyl transpeptidase and alkaline phosphatase (ALP) along with mild elevations in aminotransferases (ALT and AST) Billiary…

28. PBC:CF… PBC should be considered in patients with chronic cholestatic liver enzyme abnormalities. It is most often seen in middle-aged women. AMA testing may be negative, and it should be remembered that as many as 10% of patients with PBC may be AMA-negative. Liver biopsy is most important in this setting of AMA-negative PBC. In patients who are AMA-negative with cholestatic liver enzymes, PSC should be ruled out by way of cholangiography Billiary…

29. PBC: Treatment… Treatment of the typical manifestations of cirrhosis are no different for PBC than for other forms of cirrhosis Billiary…

30. Primary sclerosing cholangitis(PSC) As in PBC, the cause of PSC remains unknown. PSC is a chronic cholestatic syndrome that is characterized by diffuse inflammation and fibrosis involving the entire biliary tree, resulting in chronic cholestasis This pathologic process ultimately results in obliteration of both the intra- and extrahepatic biliary tree, leading to biliary cirrhosis, portal hypertension, and liver failure As the disease progresses, biliary cirrhosis is the final, end-stage manifestation of PSC Billiary…

31. PSC:CF: The usual clinical features of PSC are those found in cholestatic liver disease, with fatigue, pruritus, steatorrhea, deficiencies of fat-soluble vitamins, and the associated consequences. As in PBC,the fatigue is profound and nonspecific. Pruritus can often be debilitating and is related to the cholestasis Billiary…

32. PSC: Lab findings Patients with PSC typically are identified in the course of an evaluation of abnormal liver enzymes Most patients have at least a twofold increase in ALP and may have elevated aminotransferases as well Albumin levels may be decreased, and prothrombin times are prolonged in a substantial proportion of patients at the time of diagnosis Dx:The definitive diagnosis of PSC requires cholangiographic imaging Billiary…

33. PSC:Treatment There is no specific proven treatment for PSC Endoscopic dilatation of dominant strictures can be helpful, but the ultimate treatment is liver transplantation. A dreaded complication of PSC is the development of cholangiocarcinoma which is a relative contraindication to liver transplantation Billiary…

34. Definition : Patients with long-standing right-sided congestive heart failure may develop chronic liver injury and cardiac cirrhosis CARDIAC CIRRHOSIS

35. Etiology& pathology: In the case of long-term right-sided heart failure, there is an elevated venous pressure transmitted via the inferior vena cava and hepatic veins to the sinusoids of the liver, which become dilated and engorged with blood. The liver becomes enlarged and swollen, and with long-term passive congestion and relative ischemia due to poor circulation, centrilobular hepatocytes can become necrotic,leading to pericentral fibrosis Cardiac…

36. Clinical features: Patients typically have signs of congestive heart failure and will manifest an enlarged firm liver on physical examination. ALP levels are characteristically elevated, and aminotransferases may be normal or slightly increased with AST usually higher than ALT. It is unlikely that patients will develop variceal hemorrhage or encephalopathy Cardiac…

37. Diagnosis… The diagnosis is usually made in someone with clear-cut cardiac disease who has an elevated ALP and an enlarged liver Differentiation from Budd- Chiari syndrome (BCS) can be made by seeing extravasations of red blood cells in BCS, but not in cardiac hepatopathy. Venoocclusive disease can also affect hepatic outflow and has characteristic features on liver biopsy Cardiac…

38. There are several other less common causes of chronic liver disease that can progress to cirrhosis These include:inherited metabolic liver diseases such as hemochromatosis, Wilson’s disease, a antitrypsin (aAT) deficiency, and cystic fibrosis Other types of Cirrhosis

39. The clinical course of patients with advanced cirrhosis is often complicated by a number of important sequelae that can occur regardless of the underlying cause of the liver disease These include portal hypertension and its consequences of gastroesophageal variceal hemorrhage, splenomegaly, ascites,hepatic encephalopathy, spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, and hepatocellular carcinoma Major complications of Cirrhosis

40. Major complications…

41. Portal hypertension is defined as the elevation of the hepatic venous pressure gradient (HVPG) to >5 mmHg Portal hypertension is caused by a combination of two simultaneously occurring hemodynamic processes: (1) increased intrahepatic resistance to the passage of blood flow through the liver due to cirrhosis and regenerative nodules, and (2) increased splanchnic blood flow secondary to vasodilation within the splanchnic vascular bed Portal Hypertention

42. Portal hypertension is directly responsible for the two major complications of cirrhosis: variceal hemorrhage and ascites. Variceal hemorrhage is an immediate life-threatening problem with a 20–30% mortality rate associated with each episode of bleeding The causes of portal hypertension are usually subcategorized as prehepatic, intrahepatic, and posthepatic Prehepatic causes of portal hypertension are those affecting the portal venous system before it enters the liver; they include portal vein thrombosis and Splenic vein thrombosis Portal Hptn …

43. Posthepatic causes encompass those affecting the hepatic veins and venous drainage to the heart; they include BCS, venoocclusive disease, and chronic right-sided cardiac congestion Intrahepatic causes account for over 95% of cases of portal hypertension and are represented by the major forms of cirrhosis Intrahepatic causes of portal hypertension can be further subdivided into presinusoidal, sinusoidal, and postsinusoidal causes. Postsinusoidal causes include venoocclusive disease, whereas presinusoidal causes include congenital hepatic fibrosis and schistosomiasis. Sinusoidal causes are related to cirrhosis from various causes Portal Hptn …

44. Portal Hptn …

45. Coagulation disorders that can lead to the development of portal vein thrombosis include polycythemia vera; essential thrombocytosis; deficiencies in protein C, protein S, antithrombin 3, and factor V Leiden; and abnormalities in the gene-regulating prothrombin production. Some patients may have a subclinical myeloproliferative disorder. Portal Hptn …

46. Clinical features: The three primary complications of portal hypertension are gastroesophageal varices with hemorrhage, ascites, and hypersplenism Thus, patients may present with upper GI bleeding, which, on endoscopy, is found to be due to esophageal or gastric varices; with the development of ascites along with peripheral edema; or with an enlarged spleen with associated reduction in platelets and white blood cells on routine laboratory testing Portal HPtn …

47. Esophageal Varices: Over the last decade, it has become common practice to screen known cirrhotics with endoscopy to look for esophageal varices. Such screening studies have shown that approximately one third of patients with histologically confirmed cirrhosis have varices It is estimated that the majority of patients with cirrhosis will develop varices over their lifetimes. Furthermore, it is anticipated that roughly one-third of patients with varices will develop bleeding Patients with tense ascites are also at increased risk for bleeding from varices. Portal Hptn …

48. Esophageal Varices… Dx In patients with cirrhosis who are being followed chronically, the development of portal hypertension is usually revealed by the Presence of thrombocytopenia; the appearance of an enlarged spleen; or the development of ascites, encephalopathy, and/or esophageal varices with or without bleeding Portal Hptn …

49. Variceal Hemorrhage…Dx Varices should be identified by endoscopy. Abdominal imaging, either by computed tomography (CT) or MRI, can be helpful in demonstrating a nodular liver and in finding changes of portal hypertension with intraabdominal collateral circulation Portal Hptn …

50. Variceal Hemorrhage …Tx Treatment for variceal hemorrhage as a complication of portal hypertension is divided into two main categories: (1) primary prophylaxis and (2) prevention of rebleeding once there has been an initial variceal hemorrhage Portal Hptn …

51. Variceal Hemorrhage…Tx I n patients with cirrhosis who are screened for portal hypertension and are found to have large varices, it is recommended that they receive either beta blockade or primary prophylaxis with EVL. The approach to patients once they have had a variceal bleed is first to treat the acute bleed, which can be life-threatening, and then to prevent further bleeding Prevention of further bleeding is usually accomplished with repeated variceal band ligation until varices are obliterated. Treatment of acute bleeding requires both fluid and blood-product replacement as well as prevention of subsequent bleeding with EVL Portal Hptn

52. Variceal Hemorrhage…Tx The medical management of acute variceal hemorrhage includes the use of vasoconstricting agents, usually somatostatin or octreotide Control of bleeding can be achieved in the vast majority of cases; however, bleeding recurs in the majority of patients if definitive endoscopic therapy has not been instituted Octreotide, a direct splanchnic vasoconstrictor, is given at dosages of 50–100 µg/h by continuous infusion. Endoscopic intervention is used as first-line treatment to control bleeding acutely Portal Hptn …

53. Variceal band ligation is used to control acute bleeding in over 90% of cases and should be repeated until obliteration of all varices is accomplished. When esophageal varices extend into the proximal stomach, band ligation is less successful. Portal Hptn …

54. Prevention of recurrent bleeding Once patients have had an acute bleed and have been managed successfully, attention should be paid to preventing recurrent bleeding This usually requires repeated variceal band ligation until varices are obliterated. Beta blockade may be of adjunctive benefit in patients who are having recurrent variceal band ligation Portal Hptn …

55. Portal Hptn …

56. Splenomegaly and Hypersplenism: Congestive splenomegaly is common in patients with portal hypertension Clinical features include the presence of an enlarged spleen on physical examination and the development of thrombocytopenia and leukopenia in patients who have cirrhosis Hypersplenism with the development of thrombocytopenia is a common feature of patients with cirrhosis and is usually the first indication of portal hypertension Portal Hptn …

57. Ascites Ascites is the accumulation of fluid within the peritoneal cavity Overwhelmingly, the most common cause of ascites is portal hypertension related to cirrhosis; however, clinicians should remember that malignant or infectious causes of ascites can be present as well, and careful differentiation of these other causes are obviously important for patient care Portal Hptn …

58. Ascites…Pathogenesis The presence of portal hypertension contributes to the development of ascites in patients who have cirrhosis There is an increase in intrahepatic resistance, causing increased portal pressure, but there is also vasodilation of the splanchnic arterial system, which, in turn, results in an increase in portal venous inflow. Both of these abnormalities result in increased production of splanchnic lymph. Vasodilating factors such as nitric oxide are responsible for the vasodilatory effect. These hemodynamic changes result in sodium retention by causing activation of the renin-angiotensin-aldosterone system with the development of hyperaldosteronism Portal Hptn …

59. Ascites…Pathogenesis The renal effects of increased aldosterone leading to sodium retention also contribute to the development of ascites . Sodium retention causes fluid accumulation and expansion of the extracellular fluid volume, which results in the formation of peripheral edema and ascites . Sodium retention is the consequence of a homeostatic response caused by underfilling of the arterial circulation secondary to arterial vasodilation in the splanchnic vascular bed. Because the retained fluid is constantly leaking out of the intravascular compartment into the peritoneal cavity, the sensation of vascular filling is not achieved, and the process continues. Hypoalbuminemia and reduced plasma oncotic pressure also contribute to the loss of fluid from the vascular compartment into the peritoneal cavity. Hypoalbuminemia is due to decreased synthetic function in a cirrhotic liver Portal Hptn …

60. Portal Hptn …

61. Ascites…Clinical features Patients typically note an increase in abdominal girth that is often accompanied by the development of peripheral edema . The development of ascites is often insidious, and it is surprising that some patients wait so long and become so distended before seeking medical attention. Patients usually have at least 1–2 L of fluid in the abdomen before they are aware that there is an increase . If ascitic fluid is massive, respiratory function can be compromised, and patients will complain of shortness of breath . Hepatic hydrothorax may also occur in this setting, contributing to respiratory symptoms . Patients with massive ascites are often malnourished and have muscle wasting and excessive fatigue and weakness Portal Hptn …

62. Ascites…Diagnosis Diagnosis of ascites is by physical examination and is often aided by abdominal imaging. Patients will have bulging flanks, may have a fluid wave, or may have the presence of shifting dullness When patients present with ascites for the first time, it is recommended that a diagnostic paracentesis be performed to characterize the fluid . This should include the determination of total protein and albumin content , blood cell counts with differential, and cultures . In the appropriate setting, amylase may be measured and cytology performed Portal Hptn …

63. Ascites… Dx In patients with cirrhosis, the protein concentration of the ascitic fluid is quite low, with the majority of patients having an ascitic fluid protein concentration <1 g/dL. The development of the serum ascites-to-albumin gradient (SAAG) has replaced the descriptionof exudative or transudative fluid . When the gradient between the serum albumin level and the ascitic fluid albumin level is >1.1 g/dL , The cause of the ascites is most likely due to portal hypertension; this is usually in the setting of cirrhosis . When the gradient is <1.1 g/dL, infectious or malignant causes of ascites should be considered. When levels of ascitic fluid proteins are very low,patients are at increased risk for developing SBP. A high level of red blood cells in the ascitic fluid signifies a traumatic tap or perhaps a hepatocellular cancer or a ruptured omental varix . When the absolute level of polymorphonuclear leukocytes is >250/µL , the question of ascitic fluid infection should be strongly considered Portal Hptn …

64. Ascites…Treatment Patients with small amounts of ascites can usually be managed with dietary sodium restriction alone, <2 g of sodium per day, which is the recommended amount When a moderate amount of ascites is present, diuretic therapy is usually necessary. Traditionally , spironolactone at 100–200 mg/d as a single dose is started, and furosemide may be added at 40–80 mg/d, particularly in patients who have peripheral edema In patients who have never received diuretics before, the failure of the above-mentioned dosages suggests that they are not being compliant with a low-sodium diet . If compliance is confirmed and ascitic fluid is not being mobilized, spironolactone can be increased to 400–600 mg/d and furosemide increased to 120–160 mg/d. If ascites is still present with these dosages of diuretics in patients who are compliant with a low-sodium diet,Then they are defined as having refractory ascites , and alternative treatment modalities including repeated large-volume paracentesis or a TIPS procedure should be considered Portal Hptn …

65. Portal Hptn …

66. SBP is a common and severe complication of ascites characterized by spontaneous infection of the ascitic fluid without an intraabdominal source In patients with cirrhosis and ascites severe enough for hospitalization, SBP can occur in up to 30% of individuals and can have a 25% in-hospital mortality rate The most common organisms are Escherichia coli and other gut bacteria; however, gram-positive bacteria, including Streptococcus viridans , Staphylococcus aureus, and Enterococcus sp., can also be found . If more than two organisms are identified, secondary bacterial peritonitis due to a perforated viscus should be considered . The diagnosis of SBP is made when the fluid sample has an absolute neutrophil count >250/µL SPONTANEOUS BACTERIAL PERITONITIS( SBP)

67. Patients with ascites may present with fever, altered mental status, elevated white blood cell count, and abdominal pain or discomfort, or they may present without any of these features. Therefore,it is necessary to have a high degree of clinical suspicion, and peritoneal taps are important for making the diagnosis . Treatment is with a second-generation cephalosporin,with cefotaxime being the most commonly used antibiotic In patients with variceal hemorrhage, the frequency of SBP is significantly increased , and prophylaxis against SBP is recommended when a patient presents with upper GI bleeding Furthermore, in patients who have had an episode(s) of SBP and recovered, once-weekly administration of antibiotics is used as prophylaxis for recurrent SBP SBP …

68. The hepatorenal syndrome (HRS) is a form of functional renal failure without renal pathology that occurs in about 10% of patients with advanced cirrhosis or acute liver failure The diagnosis is made usually in the presence of a large amount of ascites in patients who have a stepwise progressive increase in creatinine . Type 1 HRS is characterized by a progressive impairment in renal function and a significant reduction in creatinine clearance within 1–2 weeks of presentation . Type 2 HRS is characterized by a reduction in glomerular filtration rate with an elevation of serum creatinine level, but it is fairly stable and is associated with a better outcome than that of type 1HRS HRS is often seen in patients with refractory ascites and requires exclusion of other causes of acute renal failure The best therapy for HRS is liver transplantation; recovery of renal function is typical in this setting Hepatorenal Syndrome

69. Portosystemic encephalopathy is a serious complication of chronic liver disease and is broadly defined as an alteration in mental status and cognitive function occurring in the presence of liver failure In acute liver injury with fulminant hepatic failure, the development of encephalopathy is a requirement for a diagnosis of fulminant failure Ammonia levels are typically elevated in patients with hepatic encephalopathy , but the correlation between severity of liver disease and height of ammonia levels is often poor Other compounds and metabolites that may contribute to the development of encephalopathy include certain false neurotransmitters and mercaptans HEPATIC ENCEPHALOPATHY

70. Clinical features: In acute liver failure, changes in mental status can occur within weeks to months. Brain edema can be seen in these patients , with severe encephalopathy associated with swelling of the gray matter. Cerebral herniation is a feared complication of brain edema in acute liver failure, and treatment is meant to decrease edema with mannitol and judicious use of intravenous fluids In patients with cirrhosis, encephalopathy is often found as a result of certain precipitating events such as hypokalemia, infection, an increased dietary protein load, or electrolyte disturbances . Patients may be confused or exhibit a change in personality. They may actually be quite violent and difficult to manage; alternatively, patients may be very sleepy and difficult to rouse . Because precipitating events are so commonly found, they should be sought carefully Hepatic Encephalopathy…

71. In patients presenting with encephalopathy, asterixis is often present The diagnosis of hepatic encephalopathy is clinical and requires an experienced clinician to recognize and put together all of the various features Hepatic Encephalopathy

72. Treatment: Treatment is multifactorial and includes management of the abovementioned precipitating factors Sometimes hydration and correction of electrolyte imbalance are all that is necessary The mainstay of treatment for encephalopathy , in addition to correcting precipitating factors, is to use lactulose, a nonabsorbable disaccharide , which results in colonic acidification The goal of lactulose therapy is to promote 2–3 soft stools per day The alternating administration of neomycin and metronidazole has commonly been used to reduce the individual side effects of each More recently, rifaximin at 550 mg twice daily has been very effective in treating encephalopathy without the known side effects of neomycin or metronidazole. Zinc supplementation is sometimes helpful in patients with encephalopathy and is relatively harmless Hepatic Encephalopathy…

73. Because the liver is principally involved in the regulation of protein and energy metabolism in the body, it is not surprising that patients with advanced liver disease are commonly malnourished. Once patients become cirrhotic, they are more catabolic, and muscle protein is metabolized. There are multiple factors that contribute to the malnutrition of cirrhosis, including poor dietary intake, alterations in gut nutrient absorption , and alterations in protein metabolism. Dietary supplementation for patients with cirrhosis is helpful in preventing patients from becoming catabolic MALNUTRITION IN CIRRHOSIS

74. Coagulopathy is almost universal in patients with cirrhosis. There is decreased synthesis of clotting factors and impaired clearance of anticoagulants . In addition , patients may have thrombocytopenia from hypersplenism due to portal hypertension Vitamin K–dependent clotting factors are factors II, VII, IX, and X . Vitamin K requires biliary excretion for its subsequent absorption; thus, in patients with chronic cholestatic syndromes, vitamin K absorption is frequently diminished . Intravenous or intramuscular vitamin K can quickly correct this abnormality . More commonly, the synthesis of vitamin K–dependent clotting factors is diminished because of a decrease in hepatic mass, and,under these circumstances , administration of parenteral vitamin K does not improve the clotting factors or the prothrombin time. Platelet function is often abnormal in patients with chronic liver disease, in addition to decreases in platelet levels due to hypersplenism. Abnormalities in Coagulation

75. Osteoporosis is common in patients with chronic cholestatic liver disease because of malabsorption of vitamin D and decreased calcium ingestion . The rate of bone resorption exceeds that of new bone formation in patients with cirrhosis,resulting in bone loss. DEXA scan shows Osteoporosis or osteopenia in patients with chronic liver disease . When a DEXA scan shows decreased bone mass, treatment should be administered with bisphosphonates that are effective at inhibiting resorption of bone and efficacious in the treatment of osteoporosis. Bone disease in Cirrhosis

76. Numerous hematologic manifestations of cirrhosis are present, including anemia from a variety of causes including hypersplenism, hemolysis,iron deficiency, and perhaps folate deficiency from malnutrition . Macrocytosis is a common abnormality in red blood cell morphology seen in patients with chronic liver disease, and neutropenia may be Seen as a result of hypersplenism Hematologic abnormalities in Cirrhosis

77. Harrison’s Principles of Internal Medicine,19 th Edition Uptodate 21.6 Referrences

78. Thank You…