Cirrhosis : Cirrhosis Ryan Ford MD
February 19, 2003 Cirrhosis : Cirrhosis Definition: Fibrosis of the liver with the formation of regenerative nodules.
Number 10 of the top 10 reasons people depart the Earth.
1.2% of all deaths and 1% of hospitalizations are due to cirrhosis and complications thereof.
Prevalence is on the rise. Pathophysiology : Pathophysiology Cirrhosis is the final common pathway of chronic liver injury. Fibrous scar tissue replaces viable hepatocytes.
Fibrosis leads to increasing resistance to blood flow through the liver.
Ascites, Portal Hypertension, Hemorrhoids, Esophageal varices. Gross PathologyHealthy Liver : Gross PathologyHealthy Liver Gross PathologyCirrhosis : Gross PathologyCirrhosis Gross Pathology Cirrhosis : Gross Pathology Cirrhosis Causes of Cirrhosis : Causes of Cirrhosis Common Causes (>80% of all cases):
Obesity Other Causes:
Primary Biliary Cirrhosis
Primary Sclerosisng Cholangitis
Alpha-1 Antitrypsin Classification of Cirrhosis : Classification of Cirrhosis Child-Pugh Child-Pugh Interpretation : Child-Pugh Interpretation Class A patients (5-7 points):
Good life expectancy, good candidates for transplantation.
Class B patients (8-10 points):
Require frequent medical attention/hospitalization and have a statistically shortened life expectancy.
Class C patients (11-15 points):
Often ICU patients Cirrhosis Evaluation : Cirrhosis Evaluation History
With careful attention to Social History
Use of I.V. drugs, alcohol use, etc.
Skin: Jaundice, Spider Angiomas, palmar erythema, caput medusae.
Nails: White nails, clubbing
Other: Splenomegaly, ascites, testicular atrophy, gynecomastia, muscle wasting. Skin Findings : Skin Findings Skin Findings : Skin Findings Cirrhosis Evaluation : Cirrhosis Evaluation Labs:
CBC, CMP, PT/INR, Hepatitis Panel
If you suspect encephalopathy… Ammonia
If you suspect hemachromatosis… iron panel
If you suspect autoimmune… ANA, AmtA, and anti-smooth muscle antibodies.
If you suspect Wilson’s… Ceruloplasmin
If you suspect alpha-1 antitrypsin… Alpha-1 Antitrypsin Level
Screen for hepatocellular carcinoma with AFP every 6 months. Cirrhosis Evaluation : Cirrhosis Evaluation Imaging
Ultrasound: Fast and cheap, good for detection cirrhosis, ascites, and other pathology.
CT: Benefit really doesn’t outweigh cost when compared to ultrasound
MRI: Generally reserved for evaluation of potential tumors within the liver. Cirrhosis Evaluation : Cirrhosis Evaluation Liver Biopsy:
Indications: Need for tissue diagnosis
Contraindicaions: Coagulopathy or ascites,
EGD: For screening for esophageal varices.
Colonoscopy: Indicated as evaluation of potential transplant candidates. Cirrhosis Treatment : Cirrhosis Treatment Prevent further liver injury
Hepatitis A & B immunization
Cessation of alcohol
Treat the cause of Cirrhosis
Hemochromatosis, alcoholism, wilson’s etc.
Treat the Complications of Cirrhosis Cirrhosis Treatment : Cirrhosis Treatment Do no Harm:
Avoid sedatives, narcotics, constipating and nephrotoxic drugs.
Avoid elective surgery
Vaccinate to Hepatitis A & B
Encourage weight loss
No lifting >40 lbs. (Valsalva) Ascites : Ascites The presence of ascites predicts a 50% mortality within 2 years.
Passive congestion leads to portal hypertension which further produces ascitic fluid. As systemic volume falls the kidneys hold on to sodium, water follows (hypervolemia) and the cycle continues.
Sodium restriction to 2g/day
Diuretic use Ascites Treatment : Ascites Treatment Drugs: Spironolactone, Loop diuretics, K-Sparing diuretics.
Paracentesis: Indicated for tense ascites despite maximal diuretic use.
Large Volume Paracentesis (LVP) can be performed in an outpatient setting up to every 2 weeks. Ascites Treatment : Ascites Treatment Peritoneovenous Shunts (PVSs):
Creates a one way bypass from the peritoneum to the superior vena cava.
Plagued by obstruction, infection and other problems.
Transjugular intrahepatic portasystemic shunt (TIPS):
Reduces ascites but greatly increases the risk of development of encephalopathy. Spontaneous Bacterial Peritonitis (SBP) : Spontaneous Bacterial Peritonitis (SBP) Bacterial infection of ascitic fluid.
Typically gut flora (E. Coli, Klebsiella, Strep)
Cefotaxime 2g IV q8h x five days
Spectrum narrowing based on culture results.
>250 PMN’s on high power field
+ Bacterial growth on culture
Absence of Surgically treatable source of infection. Hepatic Encephalopathy : Hepatic Encephalopathy Caused by absorption of toxins from the gut and the shunting of these sedating toxins past the liver to the brain. Trail Test : Trail Test Hepatic Encephalopathy : Hepatic Encephalopathy Treatment: Lactulose
Grade 0-2: Treat with oral Lactulose 30ml p.o. bid – qid as needed to have 2-3 loose stools daily.
Grade 3-4: If too somnolent or comatose to have an NGT or P.O. meds
Dr. Kumar Special: 300ml of lactulose with 700ml of tap water PR q 4-8h until pt. Is alert enough to resume oral diet. MOA of Lactulose Therapy : MOA of Lactulose Therapy Decrease production of ammonia and other toxins by intestinal flora.
Ioninic trapping (by lowering intestinal pH) and subsequent elimination.
Decreased colonic transport time (decreases absorption opportunity) Hepatic Encephalopathy : Hepatic Encephalopathy Additional Therapy:
For patients refractory to lactulose addition of neomycin may be beneficial.
500 – 1000 mg bid
Watch for potential ototoxicity/nephrotoxicity.
For patients refractory to both lactulose and neomycin…
Low protein diet. Variceal Bleeding : Variceal Bleeding Potentially fatal complication with massive GI hemorrhage.
Requires initial stabilization with IV fluids and blood. NGT with Gastric lavage in preparation for EGD with banding
Balloon tamponade for bleeding which obscures view by Endoscopy. Esophageal Varices : Esophageal Varices Prevention of Variceal Rebleeding : Prevention of Variceal Rebleeding Avoid NSAIDs Completely
Porto-systemic shunts References : References Robbins, Stanley L., Pathologic Basis of Disease, 1994, 5th edition.
White, Gary M., Diseases of the Skin, 2000, 1st edition.
Goodman, Joel G. et al., The Pharmocological Basis of Therapeutics, 1996, 9th edition.
WebPATH at University of Utah Questions??? : Questions??? Questions? I’d rather be here right now. : I’d rather be here right now.