CIRRHOSIS OF LIVER

Dr.Vemuri Chaitanya

Cirrhosis

Chronic generalized liver disease A condition that is defined histopathologically and has a variety of clinical manifestations and complications, some of which can be life threatening. Pathologic features : development of fibrosis to the point that there is architectural distortion with formation of regenerative nodules ( micronodular / macronodular ) This results in decrease in hepatocellular mass, thus function .

NORMAL

Micronodular Cirrhosis

Macronodular Cirrhosis

Epidemiology

40% cases asymptomatic It is the 12th leading cause of death in United States.

Approximately 30,000 to 50,000 deaths per year Additional 10,000 deaths due to liver cancer secondary

to cirrhosis

This end stage of CLD is characterised by :

Bridging Fibrous Septa Parenchymal nodules Disruption of the architecture of the entire liver

pathogenesis

Hepatocellular death Regeneration Progressive fibrosis The induction of fibrosis occurs with activation of hepatic stellate cells, resulting in formation of increased amounts of collagen & other components of extracellular matrix. Stimuli : 1.Chr.inflammation cytokines like TNF, Lymphotoxin, IL-1 2.Cytokine production by injured Kupffer cells, endothelial cells, hepatocytes, bile duct epithelial cells 3.Disruption of ECM 4.Direct stimulation of stellate cells by toxins

Etiology

Alcoholism Chronic Viral Hepatitis Hepatitis B Hepatitis C Autoimmune Hepatitis Nonalcoholic steatohepatitis Biliary Cirrhosis Primary biliary cirrhosis Primary sclerosing cholangitis Autoimmune cholangiopathy

Etiology
Cardiac Cirrhosis Budd Chiari Syndrome Inherited metabolic liver disease : Hemochromatosis Wilsons Disease Alpha 1 Antitrypsin deficiency Cystic Fibrosis Cryptogenic Cirrhosis Others : Galactosemia , Tyrosinemia, Drug induced : alpha methyldopa Syphilis

Clinical Features

Asymptomatic for long periods. Onset of symptoms insidious , less often abrupt. Non specific symptoms vague right upper quadrant pain, fever, nausea, vomiting,diarrhea,anorexia & malaise. Or they may present with more specific complication of CLD ascites,upper GI bleed etc

Signs

Loss of hair ( alopecia ) Icterus Pallor KF Ring Parotid enlargement Fetor hepaticus Loss of axillary & pubic hair Spider nevi Gynecomastia Atrophy of breasts in females Wasting of muscles

Signs

Glossitis, cheilitis Palmar erythema Clubbing Leuconychia Dupuytrens contracture Ascites In 70 % cases liver is enlarged, firm if not hard and nodular Splenomegaly Caput medusae

Signs

Bleeding tendencies : deficiency of clotting factors check PT /INR Fever Hyperpigmentation Hyperdynamic circulatory state Edema Hernia Testicular atrophy Delirium Constructional apraxia Flapping tremors Inversion of sleep rhythm

Palmar erythema

Alcoholic Cirrhosis

Accurate history regarding amount & duration of alcohol consumption is required. Lab tests : Completely normal in early compensated alcoholic cirrhosis Hb: Anemia + ( chr.GI loss, nutritional def, hypersplenism ) Platelet count : reduced early in disease, portal htn with hypersplenism

Alcoholic Cirrhosis

S.Bilirubin normal / elevated PT often prolonged S. Transaminases elevated AST / ALT = > 2/1 Liver biopsy Treatment : Abstinence is the cornerstone of therapy. Treatment of any complications Glucocorticoids if DF > 32 Oral Pentoxiphylline

Cirrhosis d/t Chr.Hepatitis B & C

Of patients exposed to HCV, approximately 80% develop Chronic hepatitis and of those, about 20 30 % will develop cirrhosis over 20-30 yrs. Here , liver is small & shrunken with a characteristic features of mixed micro and macro nodular cirrhosis seen on biopsy. Of patients exposed to HBV, about 5 % develop chronic hepatitis & about 20% of those patients go on to develop cirrhosis. Liver is small & shrunken and has mixed micro & macronodular cirrhotic pattern. Invg : Routine investigations + HCV RNA, HBsAg, anti HBs, HBeAg, anti HBe, HEV DNA.

Cirrhosis d/t Chr.Hepatitis B & C

Specific Treatment : HBV : Lamivudine, Adefovir, Entecavir, Tenofovir HCV: Pegylated Interferon, Ribavirin

Primary Biliary Cirrhosis

Female preponderance Median age of around 50 yrs Etiology : unknown Portal inflammation & necrosis of cholangiocytes in small and medium sized bile ducts. Antimitochondrial antibodies in 90% of pts Pathology : earliest lesion- Chronic Nonsuppurative Destructive Cholangitis

Primary Biliary Cirrhosis

Fatigue Pruritis On ex: hepatomegaly splenomegaly ascites edema Unique to PBC : Hyperpigmentation,Xanthelasma,Xanthomata

Primary Biliary Cirrhosis

LAB : Elevated GGT, ALP with mild elevations of AST & ALT Hyperbilirubinemia Thrombocytopenia, leukopenia, anemia TREATMENT : UDCA @ 13 15 mg/Kg per day Liver Transplantation Cholestyramine Bisphosphonates osteopenia/osteoporosis

Primary Sclerosing Cholangitis

Etiology : unknown Diffuse inflammation & fibrosis of entire biliary tree chronic cholestasis obliteration of intra & extrahepatic biliary tree biliary cirrhosis portal htn liver failure Cli fea : fatigue, pruritis, steatorrhea, fat sol vitamin deficiencies Lab: 2 fold rise in ALP, elevated aminotransferases, p-ANCA ( 65%) Diagnosis : MRCP , Cholangiogram Treatment : No proven treatment. High dose 20 mg/kg/day UDCA. Endoscopic dilatation of dominant strictures Liver Transplantation

Cardiac Cirrhosis

Pts with long standing right sided CHF may develop chronic liver disease & cardiac Cirrhosis Cli fea : symptoms of Rt.Heart.Failure + Hepatomegaly Lab : ALP raised, AST > ALT normal / raised Diagnosis : cardiac case with elevated ALP & enlarged liver

Cirrhosis other causes

Hemochromatosis Wilsons Disease Alpha1 Antitrypsin Deficiency Cystic Fibrosis

Investigations

Complete Hemogram
Peripheral Smear Platelet Count PT INR LFT S. Bilirubin, S. Albumin, S. Globulin, SGPT, SGOT, ALP

Hepatitis Profile
Alpha Fetoprotein

Investigations

Blood sugar Urea, Creatinine Sodium, Potassium

Ascitic fluid examination

X-Ray chest USG / CT Abdomen Confirmation by Liver Biopsy

Complications of Cirrhosis

Portal HTN Gastroesophageal Varices Portal hypertensive Gastropathy Splenomegaly, Hypersplenism Ascites SBP Hepatorenal Syndrome Type 1 & 2 Hepatic Encephalopathy Hepatopulmonary Syndrome Portopulmonary Hypertension Malnutrition

Complications of Cirrhosis

Coagulopathy : Factor deficiency Fibrinolysis Thrombocytopenia Bone Disease : Osteopenia/Osteoporosis/ Osteomalacia Haematological abn : Anaemia Hemolysis Thrombocytopenia Neutropenia

Portal Hypertension

Prehepatic :Portal Vein thrombosis Splenic Veinf Thrombosis Massive Splenomegaly Hepatic : Presinusoidal Schistosomiasis Cong.hepatic fibrosis Sinusoidal Cirrhosis Alcoholic hepatitis Postsinusoidal Veno-occlusive Disease

Posthepatic : Budd Chiari syndrome Inferior vena caval webs Cardiac Causes Restrictive Cardiomyopathy Constrictive Pericarditis Severe CHF

Portal Hypertension

1.

2.

Elevation of hepatic venous pressure gradient to > 5mm Hg. It is caused by combination of 2 simultaneously occuring hemodynamic processes : Increased intrahepatic resistance to passage of blood flow through liver Increased splanchnic blood flow secondary to vasodilation.

Portal Hypertension

Portal HTN directly responsible for 2 complications variceal haemorrhage and ascites Also hypersplenism, congestive gastropathy, renal failure and hepatic encephaopathy

CLINICAL FEATURES

Splenomegaly Hypersplenism Thrombocytopenia, Neutropenia, Anemia Dilated Abdominal Veins, Caput Medusae, Ascitis. Oesophageal varices

Variceal Bleed

Approx 5 15 % of cirrhotics per year develop varices and it is estimated that majority of patients with cirrhosis will develop varices over their lifetime 1/3rd of patients with varices develop bleeding. Factors predicting variceal bleed : Severity of cirrhosis ( Childs Class ) Ht of wedged hepatic vein pressure Size and location of varix Endoscopic stigmata : red wale sign, hematocystic spots, diffuse erythema, bluish color, cherry red spot & white nipple spot Tense ascites

Variceal Bleed

Diagnosis : identified by endoscopy Pt with a gradient of >12 mm Hg are at a greater risk for variceal bleed.
Precipitating Factors Alcohol, Aspirin, Analgesics (NSAIDs), Adrenal Corticosteroids Assessment Drop in systolic BP > 10 mmHg, rise in pulse > 15 beats / minute on sitting up 10 to 20%

Supine Hypotension - > 20%

Systolic BP < 100 mmHg / Baseline Tachycardia > 25%

Stabilize BP 2 large bore IV line

RESUSCITATION

Isotonic saline / Ringer Lactate / fresh blood / packed RBC transfusion Maintain hour pulse, BP, respiration chart (In emergency situation O-ve blood)

MEASURE URINE OUTPUT Correction of coagulopathy FFP, parenteral Vit K 10 mg Platelet transfusion if count < 50,000 Airway protection endotracheal intubation to prevent aspiration

RESUSCITATION

Nasal Gastric Aspiration OCTREOTIDE Infusion 50 to 100 gm bolus 25 to 50 gm / hour infusion VASOPRESSIN 0.3 unit / minute IV gradually increased to 0.9 units/minute Side-effects : Myocardial ischemia, infarction, arrhythmia, cardiac arrest, mesenteric ischemia ( now not preferred )

Resuscitation

Endoscopic Therapy : Variceal band ligation Variceal sclerotherapy Balloon tamponade ( Sengstaken-Blakemore tube or Minnesota tube ) in pts who cannot get endoscopic therapy or those who need stabilization prior to endoscopic therapy TIPS When esophageal varices extend into proximal stomach In Pts eho fail endoscopic / medical treatment and also poor subjects for surgery.

prophylaxis

Beta blockers propranolol resting heart rate to be reduced by 25 %. Repeated variceal band ligation until varices are obliterated.

Splenomegaly & Hypersplenism

Congestive splenomegaly is common in pts with portal htn. Clinical features include enlarged spleen, thrombocytopenia, leukopenia Some significant left sided/ left upper quadrant abdominal pain No specific treatment Splenectomy Hypersplenism with development of thrombocytopenia first indicator of portal hypertension

Ascites

Accumulation of fluid within the peritoneal cavity M.C cause : cirrhosis with portal hypertension Clinical features : increase in abdominal girth peripheral edema dyspnea if massive bulging flanks shifting dullness fluid thrill Hepatic hydrothorax more common on rt.side implicates rent in diaphragm with free flow of ascitic fluid into thoracic cavity

Ascites

Diagnostic paracentesis SAAG : >1.1g/dL portal hypertension <1.1g/Dl neoplasm,Tb, pancreatitis, Ascitic fluid proteins low high chance of developing SBP Ascitic fluid high RBCs traumatic tap, HCC, ruptured omental varix Ascitic fluid PMN >250 /cu.mm - SBP

Ascites - Treatment
Small amounts of ascites dietary sodium restriction ( <2g/day ) Moderate : diuretic is essential Spiranolactone 100-200 mg/day OD Furosemide 40-80 mg/day - if peripheral edema + Pt is compliant but ascitic fluid + , then Spiranolactone 400 -600 mg/day Furosemide 120-160 mg/day If ascites still + , then it is REFRACTORY ASCITES

Ascites - treatment
Refractory ascites Large volume paracentesis TIPS Liver Transplantation Prognosis pts of cirrhosis with ascites- poor <50 % of pts survive 2 yrs after the onset of ascites.

Spontaneous Bacterial Peritonitis

Spontaneous infection of ascitic fluid without any intraabdominal source. Bacterial translocation gut flora transversing the intestine into mesenteric lymph nodes, leading to bacteremia and seeding of ascitic fluid MC : E.coli Others : Step.viridans, Staph.aureus If > 2 organisms are identified secondary bacterial peritonitis d/t perforated viscus to be considered Ascitic fluid PMN > 250/cu.mm

SBP

Pt can present with altered sensorium, elevated WBC, abdominal pain/discomfort Treatment : cephalosporins In pts with an episode(s) of SBP and recovered , once weekly- administration of antibiotic as prophylactic measure

Hepatorenal Syndrome

Functional renal failure without renal pathology 10% of pts with cirrhosis / advanced liver failure Diagnosis : presence of large amount of ascites progressive rise in creatinine urinary sodium <10 mEq Type 1 HRS : progressive impairment of renal function & significant reduction in creatinine clearance within 12 wks . BAD PROGNOSIS Type 2 HRS : reduction in GFR, with rise in S.Creat BETTER PROGNOSIS

Hepatorenal Syndrome
Seen in refractory ascites Exclude causes of ARF Treatment: Midodrine, an alpha agonist along with Octerotide and IV Albumin Liver transplantation

HEPATIC ENCEPHALOPATHY

Precipitating factors

GI Bleeding

Excess protein intake

Electrolyte abnormalities, Ascitic Aspiration Uremia Dehydration, Constipation Alcohol

Viral infections, SBP

Anaesthetic agents, Surgery, Narcotics, Tranquilisers Hepatic toxins, Portosystemic shunts - TIPS

HEPATIC ENCEPHALOPATHY

TreatmentCORRECT/ AVOID PRECIPITATING FACTORS

Dietary protein restriction-30 - 40 gm protein / day

Non absorbable disaccharide LACTULOSE 15 to 45 ml

BID / QID Lactulose enema

Neomycin 1 gm 6th hrly

Metronidazole 250 mg 8th hrly Bowel wash / Lactobacillus

GRADING OF HEPATIC ENCEPHALOPATHY

0 Normal 1 Inverted sleep rhythm, restless 2 Lethargy, slow response 3 Drowsy, arousable but confused 4 - Coma

HEPATOPULMONARY SYNDROME
Clubbing, cyanosis, spider nevi, orthodeoxia Hypoxia in standing position-ORTHODEOXIA Hypoxia is due to intrapulmonary shunting through direct arteriovenous communications Intra Pulmonary Vascular dilatation in the absence of intrinsic cardio pulmonary disease Resistant hypoxaemia (PaO2 < 9.3 kPa or 70 mmHg), intrapulmonary vascular dilatation and chronic liver disease with portal hypertension Treatment : liver transplantation

Portopulmonary Hypertension

Similar to 'primary pulmonary hypertension defined as pulmonary hypertension with increased pulmonary vascular resistance and a normal pulmonary artery wedge pressure in a patient with portal hypertension caused by vasoconstriction and obliteration of the pulmonary arterial system and leads to breathlessness and fatigue.

MALIGNANT TRANSFORMATION

Rapid, unexplained weight loss Unexplained fever Pain in the right Hypochondrium Rapid enlargement of liver / one of the nodules Hepatic Rub / Hepatic Bruit Hemorrhagic ascitic fluid Malignant cells in cytology of Ascitic fluid Confirmation by USG / CT / AFP / Biopsy

HCC

CHILD PUGH Scoring

Clinical and biochemical measurements
Albumin (g/dl) Bilirubin (mg/dl) For cholestatic diseases : bilirubin (mg/dl) PT (secs prolonged)* Or INR* Ascites Encephalopathy (grade)

Points scored for increasing abnormality 1 2 3 > 3.5 2.8 to 3.5 < 2.8
1 to 2 <4 1 to 4 < 1.7 Absent None 2 to 3 4 to 10 4 to 6 1.7 to 2.3 Slight 1&2 >3 > 10 >6 > 2.3 Moderate 3&4

CHILD -PUGH SCORING SYSTEM

Class A 5 to 6 points Class B 7 to 9 points Class C 10 to 15 points B & C Potential candidates for Hepatic transplantation

THANK YOU