Cirrhosis and Liver Failure

Cirrhosis

• Cirrhosis is a chronic, progressive, and irreversible condition causing decreased liver function due to diffuse liver damage.
• Key causes include viral hepatitis (B and C) and chronic alcohol abuse.
• In the US, chronic alcohol abuse is the most frequent cause, but worldwide it's viral hepatitis C.
• The liver becomes fibrotic with nodules, obstructing blood and bile flow leading to liver failure.
• Cirrhosis can take up to 40 years to develop.

Clinical Manifestations: Portal Hypertension

• Portal hypertension is a manifestation of cirrhosis.
• Portal hypertension causes varicosities in the esophagus and abdomen due to increased pressure, leading to bleeding (slow or severe).
• Ascites occur due to the liver's inability to produce albumin (hypoalbuminemia), causing fluid leakage into the peritoneal space.

Clinical Manifestations: Altered Synthetic Function

• Results in changes in clotting factors because the liver synthesizes vitamin K and clotting factors.
• Leads to bleeding tendencies.
• Muscle wasting occurs due to decreased protein levels and hypoalbuminemia.

Clinical Manifestations: Hypoglycemia

• The liver stores glycogen and releases glucose when blood sugar is low.
• Liver disease prevents glycogen storage, so patients experience chronic hypoglycemia.

Clinical Manifestations: Bile Accumulation

• Causes inflammation and necrosis, leading to jaundice (yellowing of the skin).
• Jaundice occurs when bilirubin backs up into the blood due to obstructed bile ducts.
• Results in brown urine and clay-colored stools.

Clinical Manifestations: Vitamin Deficiency and Pruritus

• Leads to fat-soluble vitamin (A, D, E, K) deficiencies due to impaired liver function.
• Intense itching (pruritus) occurs due to toxin buildup and ammonia buildup in the skin.

Clinical Manifestations: Hepatic Encephalopathy

• Ammonia builds up because the liver cannot convert it into urea (BUN).
• Increased ammonia levels affect the brain, causing confusion, loss of consciousness, and encephalopathy.

Clinical Manifestations: Spontaneous Bacterial Peritonitis

• The liver's Kupffer cells, responsible for phagocytosis, are impaired.
• Leads to increased bacteria in the GI tract and potential peritonitis.

Treatment for Cirrhosis

• Complex and depends on the underlying cause.
• Antiviral agents for hepatitis.
• Avoid alcohol and hepatotoxic drugs.
• Bile-acid binding agents aid in bile excretion.

Portal Hypertension Treatment

• Treated with surgically implanted shunts (TIPS procedure) to improve blood flow.

Ascites Treatment

• Fluid restriction and low-sodium diet.
• Diuretics.
• Paracentesis to remove fluid from the peritoneal cavity.
• Shunts may also be used.

Esophageal Varices Treatment

• Treated with endoscopic procedures (banding, shunts, sclerotherapy).

Encephalopathy Treatment

• Low-protein diet to eliminate the source of protein breakdown.
• Lactulose is prescribed to promote ammonia excretion in the stool.
• Antibiotics suppress intestinal flora and decrease endogenous ammonia production.
• Liver transplant is considered for end-stage liver disease.

Hepatitis Overview

• Hepatitis is an inflammation of the liver, usually caused by viral infections.
• Other causes include alcohol, medications (acetaminophen), and autoimmune diseases.
• Can be acute (e.g., hepatitis A, acetaminophen overdose) or chronic (e.g., hepatitis C).

Types of Hepatitis

• Non-viral hepatitis is not contagious, while viral hepatitis is.
• Hepatitis A, B, C, and D are endemic to the US, with B and C being the most common.

Hepatitis A

• Transmitted through the fecal-oral route (contaminated food/water).
• Does not cause chronic infection.
• There is a vaccine available.

Hepatitis B

• Transmitted through blood and body fluids (mucosa, sex, IV drug use).
• Can lead to chronic infection.
• There is a vaccine available.

Hepatitis C

• Transmitted through blood and body fluids (mucosa, sex, IV drug use).
• 80% of cases become chronic, leading to cirrhosis.
• Prevention includes blood donor screening and behavior modification.

Hepatitis D

• Transmitted through blood and body fluids (mucosa).
• Can lead to chronic infection.
• Requires pre-existing hepatitis B to occur.
• Rare in the US.

Hepatitis E

• Transmitted through the fecal-oral route (contaminated water).
• Does not cause chronic infection.
• Rare in the US, but can be severe in pregnant women.

Acute Hepatitis: Phases

• Prodromal period: Asymptomatic, lasts two weeks after exposure.
• Icteric period: Begins with jaundice (yellow skin, eyes), lasts two to six weeks, accompanied by enlarged, tender liver, dark urine, and clay-colored stools.
• Recovery period: Begins with the resolution of jaundice.

Chronic and Fulminant Hepatitis

• Chronic hepatitis: Lasts longer than six months, varies in severity, and can deteriorate quickly.
• Fulminant hepatitis: Rapidly progressing form leading to liver failure and death.

Hepatitis: Diagnosis

• History and physical exam.
• Liver profile (liver enzymes, clotting studies).
• Liver biopsy.
• Abdominal ultrasound.

Hepatitis: Treatment

• Vaccinations are the cornerstone of prevention.
• Limit exposure to the virus.
• Hepatitis A usually resolves with no treatment.
• Other viral hepatitis types are treated with interferon injections and antiviral medications.
• Rest, nutrition, increased hydration.
• Paracentesis.
• Liver transplant, if needed.

Hepatitis A Vaccine

• Recommended for children starting at one year of age and adults at risk (travelers, men who have sex with men, IV drug users, people with liver disease).

Hepatitis B Vaccine

• Recommended for all infants (started in the early 1990s) and adults at risk (healthcare workers, men who have sex with men, IV drug users).