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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)