Liver cirrhosis (Causes, clinical manifestation, complications, diagnosis, treatment)

A short presentation on liver cirrhosis and it's complications.

1. Liver cirrhosis C auses , clinical manifestation , complications, diagnosis , treatment Ilkin B akirli

2. Introduction WHO definition: a diffuse process characterised by liver necrosis and fibrosis and conversion of normal liver architecture into structurally abnormal nodules that lack lobular organisation Chronic progressive disease of the liver characterised by extensive degeneration and destruction of parenchymal cells The liver attempts to regenerate, but the process is disorganised, resulting in abnormal blood vessel and bile duct architecture, as well as regenerative nodules on the liver

3. Causes Alcoholic Viral: HBV, HCV NAFLD (non-alcoholic fatty liver disease) Primary sclerosing cholangitis Autoimmune hepatitis Biliary cirrhosis Cystic fibrosis Hemochromatosis Wilson disease Cryptogenic (idiopathic) Alpha-antitrypsin deficiency

4. Pathophysiology Extensive fibrosis (degeneration) and regeneration of the liver leading to nodules (hepatocellular hyperplasia and angiogenesis) New vessels are formed between the hepatic artery, hepatic veins and the portal vein These blood vessels are low volume, high pressure veins that cannot carry enough blood This leads to portal hypertension

5. Clinical manifestations Symptoms Signs Asymptomatic Epistaxis Vomiting Hepatomegaly / atrophy Nausea Splenomegaly Alopecia in pubic areas Clubbing Gynecomastia Ascites Easy bruising Caput medusa Weight loss Spider telangiectasia Muscle cramps Hepatic encephalopathy Anorexia Testicular atrophy

6. Diagnosis History, child- pugh score P hysical exam (hepatomegaly, ascites, clubbing, caput medusa) Liver function tests: ↑ALT, ↑AST, normal ALP, normal GGT , normal or ↑bilirubin, ↑PTT, ↓albumin Coagulation tests: ↑PTT, increased bleeding time CBC: microcytic and macrocytic anemia, hemolysis and hypersplenism , leukopenia, thrombocytopenia Viral serology Biopsy USG, MRI, CT, ERCP/MRCP Radionuclide technetium scan Other : ↓iron and ↑ferritin in hemochromatosis , ↓alpha-antitrypsin

7. Treatment Treat the underlying cause Supportive therapy (coagulation factors, vitamin K, albumin) Lifestyle changes Treat the complications Liver transplantation

8. Complications Portal hypertension : prolonged elevated portal pressure (normal 2-5mmHg, HTN >12mmHg) . Symptoms include splenomegaly, hypersplenism , thrombocytopenia, leukopenia, caput medusa, varices, fetor hepaticus . Diagnosis made by USG and venography Treatment: terlipressin + octreotide Variceal bleeding: bleeding usually in the gastro- esophageal junction, 50% mortality Treatment: endoscopic banding, sclerotherapy, balloon tamponade, TIPSS ( transjugular intrahepatic porto -systemic shunt), beta blockers

9. Complications Ascites: accumulation of free fluid in the peritoneum Clinical: abdominal distention, shifting dullness on percussion, right side pleural effusion (10%). Diagnosis: USG, paracentesis (protein <25g/L). Risk of peritonitis Treatment: Na+ restriction, diuretics (spironolactone/furosemide), paracentesis, I.V albumin, TIPSS Hepatorenal syndrome: in 10%, severe renal vasoconstriction due to extreme under filling of renal arterial circulation Type 1: oliguria , ↑↑↑↑creatinine , poor prognosis Type 2: in refractory ascites , ↑↑creatinine, better prognosis

10. Complications Spontaneous bacterial peritonitis (SBP): sudden abdominal pain, rebound tenderness, absent peristalsis, fever, ascites, (usually) E.coli can be cultured from the fluid. Treatment: broad spectrum ATBs Hepatopulmonary syndrome: intrapulomanry shunting through arteriovenous communications, causing resistant hypoxemia (Pa02 <70mmHg) due to pulmonary hypertension and pleural effusion Congestive gastropathy : chronic gastric congestions, bleeding sites, can cause anemia. Treatment: propranolol, TIPSS