Cirrhosis (1)

CIRRHOSIS
• End stage liver disease (irreversible)
• Result from many causes of chronic liver disease:
• Viral Hepatitis (especially B and C)
• Alcoholic liver disease
• Non-alcoholic fatty liver disease

CIRRHOSIS
• Liver tissue replaced by fibrosis and nodules
• Smooth liver surface replaced by nodules
• In advanced cirrhosis, liver becomes shrunken

CLINICAL FEATURES
• Hyperammonemia
• Asterixis, confusion, coma

HYPERAMMONEMIA
TREATMENT
• Low protein diet
• Lactulose
• Synthetic disaccharide (laxative) • Colon breakdown by bacteria to fatty acids
• Lowers colonic pH; favors formation of NH4+ over NH3
• NH4 + not absorbed → trapped in colon
• Result: ↓plasma ammonia concentrations

CIRRHOSIS
CLINICAL FEATURES
• Jaundice
• Loss of bilirubin metabolism
• Hypoglycemia
• Loss of gluconeogenesis
• Coagulopathy
• Loss of clotting factors
• Elevated PT/PTT
• Hypoalbuminemia
• May cause low oncotic pressure
• Contributes to ascites, edema

• Elevated estrogen
• Normally removed by liver
• Gynecomastia in men
Testicular atrophy
• Spider angiomata
• Palmar erythema

CAPILLARY FLUID SHIFTS
• Capillary hydrostatic pressure (Pc)
• Drives fluid out of capillaries into tissues
• Capillary oncotic pressure (∏c )
• Proteins (albumin) pull water into capillaries
• Resists movement of fluid out of capillaries

PORTAL HYPERTENSION
• Blood flows portal vein → liver → hepatic vein
• Cirrhosis → obstructed flow through liver
• High pressure in portal vein (“hypertension”)

CIRRHOSIS

ASCITES AND EDEMA

VENOUS COLLATERALS
VENOUS ANASTAMOSES
• High portal pressure opens “venous collaterals”
• Connection between portal-systemic veins
• Normally small, collapsed vessels
• Engorge in portal hypertension
• Key collaterals:
• Umbilicus – physical exam finding: “caput medusa”
• Esophagus – upper gastrointestinal bleeding
• Stomach – upper gastrointestinal bleeding
• Rectum – hemorrhoids which may also bleed

ESOPHAGEAL VARICES

GASTRIC VARICES

CAPUT MEDUSA

INTERNAL HEMORRHOIDS

HYPERSPLENISM

PORTAL VEIN THROMBOSIS
• Rare cause of portal hypertension
• Acute onset abdominal pain
• Splenomegaly (palpable spleen one exam)
• May result in gastric varices with bleeding
• Liver biopsy will be normal

ASCITES
• Accumulation of fluid in peritoneal cavity
• In liver disease, from portal hypertension +/- low albumin

SAAG
SERUM ASCITES ALBUMIN GRADIENT
• Test of ascitic fluid
• Two reasons for new/worsening ascites
• Portal hypertension
• Malignancy (leaky vasculature)
• Sample of ascitic fluid via paracentesis
• Serum albumin – ascites albumin = SAAG

SAAG
SERUM ASCITES ALBUMIN GRADIENT
• SAAG >1.1 g/dL
• Large difference between serum and ascites albumin
• High pressure driving fluid (not albumin) into peritoneum
• Seen in portal hypertension
SAAG <1.1 g/Dl
Albumin levels similar between serum and ascites
• Leaky vasculature leading to fluid/albumin into peritoneum
Seen in malignant ascites (malignant cells in peritoneal cavity)

ASCITES TREATMENT
• Sodium restriction
• Spironolactone (drug of choice)
• Potassium-sparing diuretic • Blocks aldosterone distal tubule
• Most effective drug for ascites
• Loop diuretics (2nd line)
• Large volume paracentesis
• TIPS

TIPS
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT
Transjugular Intrahepatic Portosystemic Shunt
• Treatment of portal hypertension
• Creation of channel in liver
• Connects portal vein to hepatic vein

SBP
SPONTANEOUS BACTERIAL PERITONITIS
• Ascitic fluid infection
• Bacteria in gut gain entry into ascitic fluid
• Usually E. coli and Klebsiella; rarely strep/staph
• Fever, abdominal pain/tenderness
• ↑ ascitic absolute PMNs (≥250 cells/mm3)
• Common treatment:
• 3rd generation cephalosporin (cefotaxime)
• Gram positive and gram negative coverage
• Achieves good levels in ascitic fluid

MELD SCORE
MODEL FOR END-STAGE LIVER DISEASE
• Scoring system for chronic liver disease or cirrhosis
• Estimates 3-month mortality from liver disease
• Point system using:
• Bilirubin level
• Creatinine level
• INR
• >40 = 71% mortality
<9 = 2% mortality

CHILD-PUGH CLASSIFICATION
• Five variables to predict risk/survival
• Points for encephalopathy, ascites, bilirubin, albumin, PT
• Score ranges from 5 to 15
• 5 or 6: Child-Pugh class A cirrhosis
• 7 to 9: Child-Pugh class B cirrhosis
• 10 to 15: Child-Pugh class C cirrhosis (worst)

CIRRHOSIS
DIAGNOSIS
Gold standard is liver biopsy
• Not required if diagnosis is clear from history
• Done only when biopsy will change management
• Imaging (ultrasound, CT, MRI)
• May show small, nodular liver
• Not sensitive or specific for diagnosis
• More helpful for detection of hepatocellular carcinoma
• Clinical diagnosis (common)
• Presence of ascites
• Low platelet count
• Spider angiomata