Cirrhosis

Definition

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

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

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/
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
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.