liver cirrhosis assist. prof. mona arafa tropical medicine department
TRANSCRIPT
Liver Cirrhosis
Assist. Prof. Mona Arafa
Tropical Medicine Department
Objectives
1. Understand the basic mechanisms of Liver cirrhosis
2. Recognize the classic presentations of Liver cirrhosis and its complications
3. Get an idea about the management of these complications
Definition:
1. Diffuse disorder of liver characterised by;
2. Complete loss of normal architecture,
3. Replaced by extensive fibrosis with,
4. Regenerating parenchymal nodules.
▼
Loss of normal function
Pathophysiology
►Slow, insidious, progressive, chronic►Fibrous bands replace normal liver
structure► Cell degeneration occurs► Liver attempts to regenerate cells but
cells are abnormal and disorganized► Causes abnormal blood and lymph flow► Results in more fibrous tissue formation
Normal Liver
Cirrhosis
Normal Liver Histology
CV
PT
Cirrhosis
Fibrosis
Regenerating Nodule
Classification of Cirrhosis
◘ WHO divided cirrhosis into 3 categories based on morphological characteristics of the hepatic nodules
1. Micronodular
2. Macronodular
3. Mixed
Causes of Cirrhosis1. Chronic viral hepatitis(HCV, HBV±HDV)2. Metabolic: hemochromatosis, Wilson dis,
alfa-1-antitrypsin, NASH3. Prolonged cholestasis (PBC, PSC)4. Autoimmune hepatitis5. Hepatic venous outflow obstruction
(VOD, BCS, Constrictive pericarditis)6. Drugs and toxins7. Alcohol
Clinical Presentation
Stigmata of chronic liver disease. Abnormal LFTs and CBC. Radiographic abnormalities. Complication of cirrhosis. Cirrhotic appearance of the liver at
laparotomy or laparoscopy.
Clinical Features
*Fatigue, anorexia, malaise.*Weight loss & muscle wasting.*Jaundice & dark urine.*Parotid enlargement & diarrhea.*Anemia, leucopenia, thrombocytopenia.*Bleeding gum, epistaxis, ecchymosis.*Spider angioma, palmar erythema, white
nails, dilated veins.
Clinical Features Cont.
*Gynecomastia, change in body hair patterns.
*Amenorrhea, loss of libido, testicular atrophy, impotence.
*Swelling of LL and abdomen.
*Dyspnea & hypoxia.
*Increased susceptibility to infections.
“White Nails”
Palmar Erythema
Clinical Features of Cirrhosis
Prominent abdominal veins.
Complications
Portal hypertension Ascites Varices
Coagulation defects Hepatic encephalopathy Hepatocellular carcinoma Hepatorenal syndrome
Diagnosis of cirrhosis Physical examination
*Stigmata of chronic liver disease*Features of portal hypertension*Hepatic encephalopathy
Laboratory evaluation*Tests for hepatocellular necrosis*Tests for cholestasis*Tests for synthetic function*Special tests for the cause*Screening test for HCC; AFP
Diagnosis of cirrhosis Imaging modalities
*Abdominal ultrasound.
*Computed tomography (CT).
*Magnetic resonance imaging (MRI).
*Fibroscan Esophagogastroduodenoscopy (EGD). Liver Biopsy.
Prognosis
*Depends on the development of cirrhotic complication
*Assessed by Child-Turcotte-Pugh score*Model for End-stage Liver Disease (MELD)
Based on serum bilirubin, creatinine, and INRDetermine optimal timing for liver
transplantation
Child-Pugh score
score123
Albumin.>3.53.5-2.8<2.8
Bilrubin<22-3>3
AscitesAbsentMild-Moderate
Severe/Refractory
HEAbsentMild (I-II)Severe (III-IV)
PT prolongation
<4 sec.<(1.7)
4-6 sec. (1.7-2.3)
>6 sec.>( 2.3)
Class A: 5-6 Class B: 7-9 Class C: 10-15
Management
Specific treatment*Antiviral in HBV-cirrhosis*Corticosteroids in AIH*Phlebotomy in hemochromatosis
Treatment of complications Screening for HCC Liver transplantation
Portal hypertension
Definition : Increase in hepatic sinusoidal pressure to ≥ 6mm Hg.
N.B : Portal pressure must be at least 10mm Hg for gastroesophegeal varices to develop and at least 12mm Hg for varicees to bleed.
Portal hypertension is classified as : prehepatic , hepatic and post hepatic.
Prehpatic causes include:
*Splenic vien thrombosis*Portal vein thrombosis
)associated with hpercoagulable states and with malignancy(
Post hepatic causes:
*Chronic right sided heart failure*TR
*Obstructing lesions of hepatic viens and I.V.C )Budd-chiari syndrome (
Management of complications Varices
May be esophageal, gastric, colo-rectal Diagnosis
*History : Hematemesis, melena
*Physical examination
*Ultrasound abdomen
*Endoscopy
Esophageal Varices
Management of complications Varices
Management*ABC*Two IV Lines*Blood group*Resuscitation (fluid, blood, FFP)*IV vasoconstrictors (Octreotide)*Endoscopic therapy (EST, EBL)*Shunting (surgical, TIPS)
EST & EBL
Management of complications Varices
Prevention
*Endoscopy for every cirrhotic patient at diagnosis and periodically
*Treat underlying disease
*Beta blockers
*Endoscopic Band Ligation (EBL)
Ascites
Management of complications Ascites
Diagnosis*Bulging flanks, shifting dullness, fluid wave*Ultrasound*Ascites taping (SAAG, SBP)
Treatment*Salt restriction (<2gm/d)*Diuretics (spironolactone, loop diuretics)*Paracentesis
Paracentesis
Hepatic encephalopathy
Neuropsychiatric abnormalities secondary to liver disease
BRAIN
LIVER
Toxic N2 metabolites
From Intestines
Porta systemic shunts
Pathogenesis of Hepatic Encephalopathy
Management of complications Hepatic encephalopathy
Treatment*Identify and treat precipitating factor*Low protein diet*L-ornithine L-aspartate*Antibiotics
(Neomycin, metronidazole, rifaximin)*Lactulose
*Enemas*Transplantation
Thank You