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Liver Cirrhosis

Definition

  • Dysfunction of the liver from scarring as a result of long-term liver damage
  • Commonly caused by alcohol abuse or hepatitis

 

Risk factors

  • Alcohol abuse
  • Hepatitis (severe acute hepatitis, or chronic hepatitis, autoimmune)
  • Non-alcoholic fatty liver disease
    • Diabetes
    • Obesity
    • High fat diet
  • Heart failure à hepatic congestion
  • Family history
    • Haemochromotosis
    • Wilson’s disease – excessive copper accumulation
    • Cystic fibrosis
    • Budd-chiari syndrome – caused by blood clot between liver and inferior vena cava (backflow of blood, obstruction and congestion)

 

Differential diagnoses

  • Hepatitis
  • Liver cancer
  • Cholelithiasis (gallstones)
  • Schistosomiasis
  • Sarcoidosis
  • Biliary obstruction
  • Cholangitis
  • Pancreatitis
  • Peptic ulcer

 

Epidemiology

  • Is increasing yearly – is the only major cause of death in the UK to do so
  • In the last 30 years mortality from liver disease has risen 450%
  • Is the fifth biggest killer in the UK
  • Prevalence of cirrhosis was 76 per 100,000 in 2001 in adults
  • More men than women (likely to represent drinking habits)

 

Aetiology

  • Inflammatory response and damage (hepatitis)
  • Alcohol toxicity

 

Clinical features

  • About 40% are asymptomatic until late stages of disease
  • Symptoms often non-specific
    • Anorexia
    • Nausea
    • Weight loss
    • Weakness
  • Liver failure, so build-up of toxins and general malaise
  • Jaundice
  • Ascites
  • Clubbing
  • Dupytron’s contracture
  • Leukonychia
  • Palmar erythema
  • Gynecomastia
  • Hepatomegaly
  • Spider naevi
  • Caput medusa
  • Xanthalasma
  • Peripheral oedema
  • Scratch marks
  • Neurological
    • Confusion
    • Drowsiness
    • Hand flap
    • Loss of consciousness
  • Testicular atrophy/amenorrhoea

 

Pathophysiology

  • Bridging fibrous septa – linking portal triads with each other, and with central vein
    • Collagen deposits in the spaces of Disse
    • Loss of fenestrations, so impaired exchange of solute between hepatocytes and plasma
  • Parenchymal (regenerative) nodules, with scarring
    • Can be micronodules (<3mm) or macronodules (>3mm)
  • Disrupted liver architecture
    • Fibrosis and scarring, parenchyma are in abnormal structure
    • New vessels form along the fibrous septa and scarring
      • Shunting of blood in these vessels
    • The disrupted architecture may obliterate/obstruct biliary vessels, causing jaundice
  • Fibrosis is caused by:
    • Proliferation of stellate cells
    • Become highly activated into myofibroblasts – produce a lot of fibrin
    • Kupffer cells also release mediators involved in fibrogenesis

 

Investigations

  • LFT
    • Raised bilirubin
    • Raised AST
    • Raised ALT
    • Raised alkaline phosphatase
    • Raised GGT
    • Albumin may be reduced
    • INR/PT may be raised
    • White cell count and platelets may be reduced - hypersplenism
  • Liver ultrasound
    • Hepatomegaly
    • Splenomegaly
    • Focal liver lesions
    • Portal vein flow abnormality
    • Ascites
  • MRI
    • Increased caudate lobe size
    • Islands of regenerating nodules
    • MRI scoring of cirrhosis/liver failure
  • Ascitic tap
    • To check for bacterial pericarditis

 

Management

  • Alcohol abstinence
  • Ascites
    • Bedrest
    • Low salt diet
    • Fluid restriction
    • Diuretics – start with spironolactone, furosemide if don’t respond
  • Liver transplant
  • The rest of treatment is symptom control

 

Prognosis

  • 5 year survival is 50%
  • Encephalopathy, low albumin and low sodium are bad prognostic factors
  • Increased risk of liver cancer
  • Child-Pugh grading system indicates severity
    • Measures bilirubin, albumin, prothrombin ratio, ascites, encephalopathy
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