Cirrhosis

Definition

  • Replacement of normal liver tissue with fibrotic, scarred tissue
  • Decompensation: Jaundice, ascites, hepatic encephalopathy, hepatorenal syndrome, or variceal hemorrhage (1)

Signs

  • Reduced excretion of bilirubin/ammonia
    • Jaundice
    • Scleral icterus
    • Dark colored urine (as a result of increased bilirubin in the urine)
    • “Clay-colored” stools
    • Asterixis and encephalopathy
  • Increased portal venous system pressures
    • Hepatosplenogmegaly
    • Caput medusae
    • Thrombocytopenia (from splenic sequestration)
  • Reduced hepatic metabolism of estrogen
    • Palmar erythema
    • Spider angiomata
    • Gynecomastia
    • Dupuytren’s contractures
    • Testicular atrophy
  • Reduced synthetic function
    • Hypoalbuminemia
    • Elevated INR (lack of clotting factors)

Diagnosis

  • A liver biopsy is confirmational of the diagnosis, but generally a clinical diagnosis can be made on the grounds of history, physical exam, laboratory tests, and imaging (usually ultrasound and fibroscan) (2)

Etiologies

  • Chronic heavy alcohol use
  • Non-Alcoholic Steatohepatitis (NASH)
  • Viral Hepatites (HBV, HCV mainly)
  • Primary Sclerosing Cholangitis (PSC)
  • Primary Biliary Cirrhosis (PBC)
  • Wilson’s Disease
  • Hemochromatosis
  • Autoimmune hepatitis

Management

  • Ascites
    • Dietary restrictions: Low sodium (<2g/day), low fluid (<2L/day)
    • Spironolactone and furosemide (“Magic” ratio is 100mg:40mg, respectively)
    • Paracentesis
      • SAAG (Serum-Ascites Albumin Gap) = Serum Albumin – Ascitic Albumin
        • > 1.1 = transudative (from increased hydrostatic pressure, such as in portal hypertension)
          • Total Ascitic Protein < 2.5 – portal hypertension likely hepatic in origin
          • Total Ascitic Protein > 2.5 – portal hypertension likely cardiac in origin
        • < 1.1 = exudative (from increased capillary permeability, such as in tuberculosis or malignancy)
    • TIPS (Transjugular Intrahepatic Portal Shunt): Shunt from portal vein to either IVC or hepatic vein to decrease portal venous pressure
  • Varices
    • Need screening EGD every 2 years
      • No varices seen
        • Repeat EGD in 2 years
      • Small varices seen
        • Start non-selective beta-blocker (propranolol, nadolol, carvedilol)
      • Large varices seen
        • Option of endoscopic variceal ligation in addition to non-selective beta-blocker initiation
  • Encephalopathy
    • Lactulose and rifaximin administration with the goal of 2-3 bowel movements per day to help aid the removal of ammonium from the GI tract
  • Hepatocellular Carcinoma Screening
    • Ultrasound +/- AFP every 6 months

References

  1. Mansour, D., & McPherson, S. (2018, April 1). Management of decompensated cirrhosis. Retrieved November 06, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6334027/
  2. Heidelbaugh, J., & Bruderly, M. (2006, September 01). Cirrhosis and Chronic Liver Failure: Part I. Diagnosis and Evaluation. Retrieved November 06, 2020, from https://www.aafp.org/afp/2006/0901/p756.html
  3. Yilmaz, N., Yilmaz, U., Suer, K., Goral, V., & Cakir, N. (2018, August 16). Screening for hepatocellular carcinoma: Summary of current guidelines up to 2018. Retrieved January 30, 2021, from https://hrjournal.net/article/view/2745#:~:text=From%20North%20America,(AFP)%20every%206%20months.

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