Cirrhosis
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]
Causes
- Hepatitis chronic B and C
- Alcoholic liver disease
- Non-alcoholic steatohepatitis
- Drug induced (ie. Tylenol. amiodarone, NRTIs])
- Cardiac Cirrhosis
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Autoimmune hepatitis
- Alpha1 anti-trypsin Deficiency
- Cystic Fibrosis
Sites of Portalcaval Anastomosis
Clinical presentations of portal hypertension include:
| Region | Name of clinical condition | Portal circulation | Systemic circulation |
| Esophageal | Esophageal varices | Esophageal branch of left gastric vein | Esophageal branches of azygos vein |
| Rectal | Rectal varices | Superior rectal vein | Middle rectal veins and inferior rectal veins |
| Paraumbilical | Caput medusae | Paraumbilical veins | Superficial epigastric vein |
| Retroperitoneal | Splenorenal shunt | Splenic vein | Renal vein, suprarenal vein, paravertebral vein, and gonadal vein |
| (no clinical name) | Right colic vein, middle colic vein, left colic vein | Retroperitoneal veins of Retzius | |
| Intrahepatic | Hepatic pseudolesions | Perihepatic veins of Sappey | Superior epigastric vein |
| Patent ductus venosus | Left branch of portal vein | Inferior vena cava |
A dilated inferior mesenteric vein may or may not be related to portal hypertension. Other areas of anastomosis include the bare area of the liver as it connects to the diaphragm, the posterior portion of the gastrointestinal tract as it touches the posterior abdominal wall, the posterior surface of the pancreas, and the inferior part of the esophagus.
Clinical Features
Ascites secondary to cirrhosis.
- May be asymptomatic initially
- Malaise, weakness (from electrolyte derangements)
- Abdominal pain
- Ascites, SBP (fever, abdominal tenderness)
- Altered mental status due to hepatic encephalopathy
- Coagulopathy
- GI bleed
Differential Diagnosis
Abdominal distention
- Obesity
- Intestinal obstruction
- Pregnancy
- Ascites
- Cirrhosis
- Malignancy
- Heart failure
- Tuberculosis
- Spontaneous bacterial peritonitis
- Peritoneal dialysis-associated peritonitis
- Distended bladder / Acute urinary retention
- Constipation / fecal impaction
- Large tumor(s) (e.g. ovarian, lymphoma)
- Organomegaly
Hepatic Dysfunction
Infectious
- Hepatitis
- Malaria
- HIV (present in 50% of AIDS patients)[2]
- EBV
- Babesiosis, leptospirosis
- Typhoid
- Hepatic abscess, amebiasis
Neoplastic
Metabolic
Biliary
- Biliary cirrhosis
Drugs
- Alcoholic cirrhosis
- Alcoholic hepatitis
- Hepatotoxic drugs
Miscellaneous
- Other causes of cirrhosis
- Autoimmune hepatitis
- Veno-occlusive disease
- CHF (right heart failure)
Evaluation
Workup
Diagnosis
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
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
Prognosis
Child-Pugh Score[3]
| +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[4]
| MELD-Na Score | 3-month mortality |
|---|---|
| 40 | 71.3% |
| 30-39 | 52.6% |
| 20-29 | 19.6% |
| 10-19 | 6.0% |
| <9 | 1.9% |
See Also
External Links
References
- ↑ Heron M. Deaths: Leading Causes for 2013. Natl Vital Stat Rep 2016: 16;65(2):1-95.
- ↑ Tintanelli's
- ↑ Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64
- ↑ 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.