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

• • • Contraindications
      • DIC only
  • 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)