Cirrhosis: Difference between revisions
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===Background===
==Background==
A generally irreversible fibrotic scaring of the liver parenchyma.
*A generally irreversible fibrotic scarring of the liver parenchyma resulting in liver failure
*The twelfth leading cause of death in men and women in 2013<ref>Heron M. Deaths: Leading Causes for 2013. Natl Vital Stat Rep 2016: 16;65(2):1-95.</ref>


===Differential===
==Clinical Features==
* [[Hepatitis]] chronic B and C
*May be asymptomatic initially
* Alcoholic liver disease
*Malaise, weakness (from electrolyte derrangements)
* Non-alcoholic steatohepatitis
*[[Abdominal pain]]
* Drug induced (ie. [[Tylenol]])
*[[Ascites]], [[SBP]] (fever, abdominal tenderness)
* Cardiac Cirrhosis
*[[Altered mental status]] due to [[hepatic encephalopathy]]
* Primary biliary cirrhosis
*Coagulopathy
* [[Primary sclerosing cholangitis]]
*[[GI bleed]]
* Autoimmune Hepatitis
* Alpha1 anti-trypsin Deficiency
* Cystic Fibrosis


===Clinical Features===
===Child-Pugh Score[http://www.mdcalc.com/child-pugh-score-for-cirrhosis-mortality/ <ref>Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64</ref>]===
 
'''[http://www.mdcalc.com/child-pugh-score-for-cirrhosis-mortality/ Child-Pugh Classification for Cirrhosis Mortality]'''
{| class="wikitable"
{| class="wikitable"
|-
|-
!  !! +1 !! +2 !! +3
!  !! +1 !! +2 !! +3
|-
|-
| Bilirubin|| <2 mg/dL || 2-3 mg/dL || >3 Mg/dL
| Bilirubin|| <2mg/dL || 2-3mg/dL || >3 Mg/dL
|-
|-
| Albumin || >3.5 mg/dL || 2.8-3.5 mg/dL || <2.8 mg/dL
| Albumin || >3.5mg/dL || 2.8-3.5mg/dL || <2.8mg/dL
|-
|-
| INR || <1.7 || 1.7-2.2 || >2.2
| INR || <1.7 || 1.7-2.2 || >2.2
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* Score ≤ 7 = Class A = 100% and 85% one and two-year patient survival
*Score ≤ 7 = Class A = 100% and 85% one and two-year patient survival
* Score 7 - 9 = Class B = 80% and 60% one and two-year patient survival
*Score 7 - 9 = Class B = 80% and 60% one and two-year patient survival
* Score ≥ 10 = Class c = 45% and 35% one and two-year patient survival
*Score ≥ 10 = Class c = 45% and 35% one and two-year patient survival
<br />
<br />
'''[http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/ MELD-Na Score (Model End Stage Liver Disease)]'''
===MELD Score[http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/ <ref>Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D'Amico G, Dickson ER, Kim WR. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001 Feb;33(2):464-70.</ref>]===
{| class="wikitable"
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===Management===
==Differential Diagnosis==
*[[Hepatitis]] chronic B and C
*Alcoholic liver disease
*Non-alcoholic steatohepatitis
*Drug induced (ie. [[Tylenol]]. [[amiodarone]], NRTIs])
*[[Congestive heart failure (CHF)|Cardiac Cirrhosis]]
*Primary biliary cirrhosis
*[[Primary sclerosing cholangitis]]
*[[Autoimmune hepatitis]]
*Alpha1 anti-trypsin Deficiency
*[[Cystic Fibrosis]]
 
==Management==
'''Complications of cirrhosis'''
*[[Ascites]]
*Esophageal varices
*[[Hepatic encephalopathy]]
*[[Spontaneous bacterial peritonitis]]
*[[Hepatorenal syndrome]]
*Portal hypertension
*[[Upper gastrointestinal bleed]]
*Hepatocellular carcinoma
 
'''Pain management in cirrhotic patients'''
*[[Acetaminophen]] is safe for short-term use at reduced dose of 2 grams total per day
*[[Gabapentin]] or [[pregabalin]] for neuropathic pain
*Avoid [[NSAIDs]]
*Avoid [[opioids]]
**unpredictable effects if liver function impaired due to hepatic metabolism
**if necessary, [[fentanyl]] or [[tramadol]] probably safest
 
==Disposition==
*Often complex and should be based on presence/absence of acute complications
*If no complications present, discussion with patient's primary care provider or gastroenterologist recommended
 
==See Also==
*[[Viral hepatitis]]
*[[Acute hepatic failure]]
*[[Jaundice]]
 
==External Links==
 
==References==
<references/>


===Disposition===
[[Category:GI]]

Revision as of 18:33, 28 March 2017

Background

  • A generally irreversible fibrotic scarring of the liver parenchyma resulting in liver failure
  • The twelfth leading cause of death in men and women in 2013[1]

Clinical Features

Child-Pugh Score[2]

+1 +2 +3
Bilirubin <2mg/dL 2-3mg/dL >3 Mg/dL
Albumin >3.5mg/dL 2.8-3.5mg/dL <2.8mg/dL
INR <1.7 1.7-2.2 >2.2
Ascites No ascites Ascites, medically controlled Ascites, poorly controlled
Encephalopathy No encephalopathy Encephalopathy, medically controlled Encephalopathy, poorly controlled
  • Score ≤ 7 = Class A = 100% and 85% one and two-year patient survival
  • Score 7 - 9 = Class B = 80% and 60% one and two-year patient survival
  • Score ≥ 10 = Class c = 45% and 35% one and two-year patient survival


MELD Score[3]

MELD-Na Score 3-month mortality
40 71.3%
30-39 52.6%
20-29 19.6%
10-19 6.0%
<9 1.9%

Differential Diagnosis

Management

Complications of cirrhosis

Pain management in cirrhotic patients

Disposition

  • Often complex and should be based on presence/absence of acute complications
  • If no complications present, discussion with patient's primary care provider or gastroenterologist recommended

See Also

External Links

References

  1. ↑ Heron M. Deaths: Leading Causes for 2013. Natl Vital Stat Rep 2016: 16;65(2):1-95.
  2. ↑ Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64
  3. ↑ Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D'Amico G, Dickson ER, Kim WR. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001 Feb;33(2):464-70.
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