cirrhosis. term was 1st coined by laennec in 1826 cirrhosis is the end result of many chronic...
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CIRRHOSIS
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CIRRHOSIS
Term was 1st coined by Laennec in 1826
Cirrhosis is the end result of many chronic liver diseases.
DEFINITION: It is defined histologically as presence of fibrosis and regenerative nodules in the liver
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Causes
Alcohol 60-70% Chronic viral hepatitis(B or C) 10% Non alcoholic fatty liver disease Immune primary sclerosing cholangitis autoimmune liver disease Primary Biliary cirrrhosis
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Cont…
Genetic haemochromatosis alpha-antitrypsin deficiency wilson’s disease.o Cryptogenic 10-15%o Drug induced
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Cirrhosis: Pathophysiology Primary event is injury to hepatocellular
elements Destruction of hepatocytes, bile duct cells,
vascular endothelial cells Repair through cellular proliferation and
regeneration Formation of fibrous scar Prevents normal flow of nutrients to
hepatocytes and increases vascular resistance
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Cirrhosis: Pathophysiology
Initially, fibrosis may be reversible if inciting events are removed
With sustained injury, process of fibrosis becomes irreversible and leads to cirrhosis
Cirrhotic levels of alcohol in: males >60-80g/day for 10yrs females 20-40g/day for 10yrs.
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Normal liver Cirrhotic liver
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Classification of Cirrhosis
WHO divided cirrhosis into 3 categories based on morphological characteristics of the hepatic nodules
1. Micronodular2. Macronodular3. Mixed
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Micronodular Cirrhosis Nodules are <3 mm in diameter Relatively uniform in size Distributed throughout the liver Liver is of uniform size or mildly
enlarged Reflect relatively early disease
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Micro nodular cirrhosis
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Macronodular & Mixed Cirrhosis Nodules are >3 mm in diameter and vary
considerably in size Usually contain portal tracts and efferent
veins Liver is usually normal or reduced in size Mixed pattern if both type of nodules are
present in equal proportions
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Macronodular cirrhosis
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Clinical features Hepatomegaly Jaundice Ascites Circulatory changes 1)spider naevi 2)palmar erythema 3)cyanosis Endocrine changes loss of libido,hair loss men- gynaecomastia , testicular atrophy,impotence female-breast atrophy, irregular menses,amenorrhoea
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PALMAR ERYTHEMA
SPIDER NAEVI
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Haemorrhagic tendency bruises,purpura,epistaxis,menorrhagia Portal hypertension splenomegaly,collateral vessels,variceal
bleeding,fetor hepaticus. Hepatic encephalopathy Other features- pigmentation,clubbing.
PURPURA
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Investigation Complete blood picture -anemia - leucopenia and thrombocytopenia -acanthocytosis Liver function tests -hyperbilirubinaemia - A:G ratio reversal -transaminases-AST and ALT raised. -alkaline phosphatase may be mildly raised Prothrobin time-prolonged Hepatitis B and C markers Blood ammonia- is raised Respiratory alkalosis
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Metabolic abnormalities glucose intolerance hyponatraemia hypokalaemia hypomagnesaemia hypophosphataemia Ultrasonic examination liver size and echotexture alteration splenic size collaterals ascites size of portal vein. Liver biopsy confirms the diagnosis
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Treatment Treatment of underlying
cause,removal of causitive agents like drugs,alcohol.
High protein diet, minimum 1g/kg/day 2000-3000 kcal/day Multivitamin supplementation Specific treatment of complications Liver transplantation
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Prognosis-Child-Pugh classification
SCORE 1 2 3
Encephalopathy
none mild marked
Bilirubin <34 34-50 >50
Albumin >35 28-35 <28
Prothrobin time
<4 4-6 >6
Ascites none mild marked
<7-child’s A, 7-9-child’s B, >9-child’s C
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COMPLICATIONS
Portal hypertension Ascites Bacterial peritonitis Hepatic encephalopathy Renal failure Portal vein thrombosis Hepatocellular carcinoma
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