Cirrhosis
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Author: Brad Fedor
Definition: Fibrosis and regenerative nodules resulting from hepatocellular injury à Irreversible architectural changes to liver
Etiologies:
- Alcohol, NASH
- Viral Hepatitis:
- Hep B --> HCC w/o Cirrhosis
- Hep C --> Cirrhosis --> HCC
- Autoimmune Hepatitis
- Metabolic Disease: Wilson’s, Hemochromatosis, α-1 AT deficiency
- Biliary Tract:
- Primary Biliary Cirrhosis (♀, Anti-mitochondrial Ab, Mononuclear infiltrate + bile duct destruction)
- Primary Sclerosing Cholangitis (♂, Inflammation, fibrosis, and strictures of hepatic bile ducts)
- Vascular: Budd-Chiari, R-sided CHF, Sinusoidal obstruction syndrome
- Meds: Tylenol, Chemo, Supplements
- Infection: CMV, TB
Decompensated Cirrhosis = Jaundice, Variceal bleed, encephalopathy, ascites
Physical Exam:
- Liver: Enlarged, firm, eventually shrunken and nodular
- Asterixis (negative myoclonus, sign of encephalopathy)
- Ascites
- Splanchnic Vasodilation à Sequestering of blood à éRAAS
- Liver also can’t get rid of Aldosterone
- Shifting dullness (wait 30 seconds to repercuss)
- Flank dullness (NPV)
- Fluid shift (PPV)
- Estradiol excess
- Gynecomastia (rim of breast tissue around nipple vs cancer), Palmar Erythema, Spider Angiomata, Testicular atrophy
- Hand: Dupuytren’s contractures, White nail lines (Muehrcke’s lines), White Nail beds (Terry’s nails)
- Clubbing (Hepatopulmonary syndrome, Megakaryocytes not inactivated when they pass through pulmonary system)
- Leukonychia (edema under nail from low albumin)
- Parotid Gland enlargement (Alcoholic cirrhosis)
Workup:
- Abdominal U/S w/ Doppler: Liver Size, R/o HCC, Ascites, Patency of Portal, splenic, and Hepatic Veins
- Determine etiology
- Viral Hepatitis Panel
- Autoimmune Hepatitis: ANA, IgG, anti-smooth muscle Ab
- Hemochromatosis: Iron studies, Liver Bx (Best)
- Wilson’s Disease: Ceruloplasmin, Liver Bx
- PSC: MRCP – Beads on a string, Bx – Onion skin fibrosis
- Ascites
- Paracentesis
- Indications
- New Onset Ascites
- Progressive Symptoms
- Tap during new admission
- Indications
- Paracentesis
-
-
- Contraindications
- DIC only
- Contraindications
- Treatment
- Restrict Na+
- 100 spirinolactone : 40 furosemide
- Dose to maintain Eukalemia
- No response? à Increase Dose (Max 4x starting amount)
- Still no response? àRepeat paracentesis, TIPs (Increase R side return)
- TIPS CI: Encephalopathy, Pulm HTN, Portal vein Thrombosis
-
SAAG >1.1 |
SAAG <1.1 |
|
Total Protein <2.5 |
Sinusoidal Portal HTN/Cirrhosis |
Nephrotic syndrome |
Total Protein >2.5 |
Postsinusoidal Budd chiari, Cor pulmonale (RSHF) |
Infection Inflammation Neoplasm |
Sinusoidal (within liver, TP <2.5)
Post Sinusoidal (Past Liver, TP >2.5)
Liver Transplant
- OLD: Child Pugh – Encephalopathy, Ascites (too objective)
- NEW: MELD – INR, Cr, Bilirubin
- Indications
- Recurrent/severe encephalopathy
- Refractory Ascites
- SBP
- Recurrent Variceal bleeding
- HRS, HPS, HCC
- Acute liver failure
- CI: EtOH w/in last 6 months, sepsis, significant comorbidity
- Survival
- 1 – year --> 90%
- 5 – years ..> 80%
Spontaneous Bacterial Peritonitis (SBP)
- Infection of Peritoneal Fluid without disrupting viscus
- Causes: Translocation or Sepsis
- Bowel Wall edema → Lowered immune status
- Ig/Complement gets diluted in Ascites
- High mortality rate from Hepatorenal syndrome
- Treatment
- Cover GNR for 5-7 days
- Give Albumin Day 1 + 3 to prevent Hepatorenal syndrome
- PPx if:
- GI bleed → Ceftriaxone (7 days)
- Hx SBP → Fluoroquinolone
- SAAG <1 → Low immunoglobin (Abx until d/c)
- Varices → Propanolol or (large) banding
- Causes: Splanchnic Vein Thrombosis, HVT, Cirrhosis
Hepatic Encephalopathy
- Failure of Liver to detoxify NH3 à Cerebral edema
- Stages
- Confusion
- Drowsiness
- Stupor
- Coma
- Signs
- Reversal of sleep-wake cycle
- Mood changes
- Asterixis
- Lethargy, confusion
- Constructional Apraxia (Can’t draw clock)
- Treatment
- Lactulose – Gut bacteria converts drug to lactic acid à Converts NH3 à NH4+ (preventing its reabsorption)
- Rifaxamin – Inhibits Gut bacterial synthesis (binds to RNA polymerase)