Health Risks: Morbidity and Mortality Factors

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Questions and Answers

Which of the following is an increasing reason for morbidity and mortality but remains less common than heart disease, cancer, and stroke?

Cirrhosis (correct)

Pancreatitis

Gastroesophageal reflux disease (GERD)

Gallstones

Who typically manages the majority of liver-related conditions such as cirrhosis and chronic viral hepatitis?

Cardiologists

Hepatologists (correct)

Oncologists

Nephrologists

Who typically manages the majority of liver-related conditions such as cirrhosis and chronic viral hepatitis?

Cardiologists

Hepatologists (correct)

Oncologists

Nephrologists

Which of the following is NOT a recognized cause of liver damage?

High blood pressure Signup and view all the answers

What is the primary function of hepatic stellate cells in the liver?

Storage of vitamin A Signup and view all the answers

What is the consequence of drinking excessive alcohol over time on the liver?

Fatty liver disease Signup and view all the answers

Which of the following statements about the blood supply to the liver is correct?

The liver has a dual blood supply from the hepatic artery and portal vein. Signup and view all the answers

In liver anatomy, what separates the plates of hepatocytes?

Sinusoids Signup and view all the answers

What is the impact of portal hypertension on renal function?

Decreases renal perfusion and glomerular filtration rate. Signup and view all the answers

Which complication is commonly associated with decompensated cirrhosis?

Hepatorenal syndrome Signup and view all the answers

What physiological change leads to ascites in the setting of portal hypertension?

Higher mean hydrostatic pressure and lower oncotic pressure. Signup and view all the answers

How does the body's response to splanchnic vasodilation affect blood flow?

It increases blood flow to the intestines and simultaneously increases portal pressure. Signup and view all the answers

What is the prognosis of compensated cirrhosis compared to decompensated cirrhosis?

Decompensated cirrhosis has a much lower median survival rate. Signup and view all the answers

What role does the renin-angiotensin-aldosterone system play in response to portal hypertension?

It causes sodium and water retention to compensate for low blood volume. Signup and view all the answers

Which of the following is least likely to trigger the decompensation of compensated cirrhosis?

Increasing physical activity Signup and view all the answers

What is a common consequence of intrahepatic porto-systemic shunts?

Reduced perfusion of the liver. Signup and view all the answers

What factor primarily contributes to the 'capillarisation' of sinusoids in chronic liver disease?

Increased portal pressure leading to liver fibrosis. Signup and view all the answers

Which therapy is typically used to manage portal hypertension?

Transjugular intrahepatic porto-systemic shunt (TIPS) Signup and view all the answers

What is the primary function of bile formed by hepatocytes?

To assist in digestion by emulsifying fats Signup and view all the answers

In relation to liver anatomy, what best describes the acinus?

A functional unit associated with one portal tract and adjacent lobules Signup and view all the answers

What is the most significant consequence of chronic passive venous congestion in the liver?

Formation of 'nutmeg liver' Signup and view all the answers

What is the effect of ischaemic injury to the liver?

Marked elevation of liver blood tests Signup and view all the answers

What type of injury is characterized by bridging necrosis in the liver?

Extensive cell death connecting portal tracts and central vein Signup and view all the answers

Which of the following defines cirrhosis?

Diffuse distortion of liver architecture with fibrous bands Signup and view all the answers

What role does the common bile duct play in liver function?

Drain bile from the liver into the duodenum Signup and view all the answers

What is the outcome of ongoing liver damage without acute liver failure?

Progression to chronic liver disease Signup and view all the answers

Which factor most significantly affects the susceptibility to ischaemic hepatitis?

Chronic cirrhosis or venous congestion Signup and view all the answers

In the assessment of liver damage, which method is used to evaluate fibrosis stage?

Liver biopsy with trichrome staining Signup and view all the answers

What is the primary reason for increased hepatic resistance to portal blood flow in cirrhosis?

Structural changes due to fibrosis Signup and view all the answers

What is characteristic of the liver in cases of chronic liver inflammation?

Increased risk of hepatocellular carcinoma Signup and view all the answers

How is the liver's immune function primarily categorized?

A buffer between the gut and the rest of the body Signup and view all the answers

What is one of the main signs of increased hepatic venous pressure gradient (HVPG) in cirrhosis?

Development of collateral circulation Signup and view all the answers

General practitioners (GPs) are most likely to be involved in the management of which liver-related issue?

Abnormal liver blood tests Signup and view all the answers

Which of the following factors differentiates patterns of cirrhosis depending on the region of the world?

Alcohol use versus chronic viral disease Signup and view all the answers

In Western countries, which of the following tumors is more likely to affect the liver?

Liver metastases Signup and view all the answers

What is the most common liver tumor globally, particularly in regions where viral hepatitis is prevalent?

Hepatocellular carcinoma Signup and view all the answers

Which of the following is a major cause of liver damage associated with metabolic syndrome, including conditions like type 2 diabetes mellitus and obesity?

Non-alcoholic fatty liver disease (NAFLD) Signup and view all the answers

Which viral infections can cause both acute and chronic liver damage?

Hepatitis B and C Signup and view all the answers

Inherited metabolic disorders such as hemochromatosis (HFE) and Wilson's disease cause liver damage by affecting which of the following?

Iron and copper metabolism Signup and view all the answers

Which of the following is NOT a cause of autoimmune-related liver damage?

Drug-induced liver injury Signup and view all the answers

Chronic biliary disease can lead to liver damage due to retained bile salts. Which condition is most likely associated with this mechanism?

Primary biliary cirrhosis Signup and view all the answers

Chronic biliary disease can lead to liver damage due to retained bile salts. Which condition is most likely associated with this mechanism?

Primary biliary cirrhosis Signup and view all the answers

Liver damage due to vascular causes may result from which of the following mechanisms?

Congestion or ischemia Signup and view all the answers

Which of the following conditions is associated with liver damage due to a deficiency of alpha-1 antitrypsin (A1AT)?

Cirrhosis Signup and view all the answers

Which of the following drugs is most likely to cause liver damage with prolonged use?

Acetaminophen (Paracetamol) Signup and view all the answers

Which of the following provides the dual blood supply to the liver?

Hepatic artery and portal vein Signup and view all the answers

The blood flowing into the liver sinusoids is separated from the hepatocytes by which of the following?

The Space of Disse Signup and view all the answers

The blood flowing into the liver sinusoids is separated from the hepatocytes by which of the following?

The Space of Disse Signup and view all the answers

Which type of cells line the liver sinusoids and play a key role in immune defense?

Kupffer cells Signup and view all the answers

Hepatic stellate cells are located in which of the following regions of the liver?

Space of Disse Signup and view all the answers

What is the primary function of hepatic stellate cells in a healthy liver?

Vitamin A storage and regulation of extracellular matrix production Signup and view all the answers

Hepatic stellate cells can become activated in liver injury and contribute to which pathological process?

Cirrhosis and fibrosis Signup and view all the answers

Which of the following accurately describes the drainage pathway of venous blood from the liver?

Hepatic vein → Inferior vena cava → Right ventricle Signup and view all the answers

What type of endothelium lines the liver sinusoids, allowing efficient exchange between blood and liver cells?

Fenestrated endothelium Signup and view all the answers

In the liver, blood flows from the portal tract through the sinusoids and drains into which structure?

Hepatic venule Signup and view all the answers

Which of the following best describes the smallest branches found in the portal tract?

Portal vein, hepatic artery, bile duct Signup and view all the answers

Which of the following statements about liver plates is correct?

They allow restricted blood flow between hepatocytes. Signup and view all the answers

In the liver acinus, where is ischemic or toxic injury most likely to be most severe?

Zone 3 Signup and view all the answers

What is the primary role of bile canaliculi in liver microanatomy?

They drain bile from hepatocytes. Signup and view all the answers

Which two ducts form the common bile duct?

Cystic duct and common hepatic duct Signup and view all the answers

What percentage of individuals have the common bile duct joining with the pancreatic duct at the ampulla of Vater?

75% Signup and view all the answers

In the liver acinus model, what does each acinus refer to?

Hepatocytes and sinusoids from two adjacent lobules supplied by one portal tract Signup and view all the answers

Chronic venous congestion of the liver is most often associated with which of the following conditions?

Right heart failure Signup and view all the answers

Budd-Chiari syndrome refers to the obstruction of venous outflow from the liver. Which of the following veins is most commonly involved?

Hepatic vein Signup and view all the answers

Which condition is commonly associated with a mild elevation of liver blood tests (ALT, AST) due to passive venous congestion?

Constrictive pericarditis Signup and view all the answers

Which of the following best describes Budd-Chiari syndrome?

Obstruction to venous outflow from the liver Signup and view all the answers

Ischaemic injury to the liver, also known as 'shock liver' or 'ischaemic hepatitis,' is typically caused by:

Hypoperfusion or circulatory failure Signup and view all the answers

Which of the following conditions increases susceptibility to ischaemic liver injury?

Passive venous congestion or cirrhosis Signup and view all the answers

In ischaemic hepatitis ('shock liver'), what is typically observed in liver blood tests?

Marked elevation of ALT and AST Signup and view all the answers

Liver infarction is extremely unusual due to the dual blood supply from which two sources?

Portal vein and hepatic artery Signup and view all the answers

Which type of heart failure is most commonly associated with passive venous congestion of the liver?

Right heart failure Signup and view all the answers

What is the characteristic gross appearance of a liver affected by chronic passive venous congestion?

"Nutmeg liver" with congested areas around central veins Signup and view all the answers

Which of the following is a primary function of the liver in the digestive system?

Synthesis of bile salts for fat digestion Signup and view all the answers

Which fat-soluble vitamins are absorbed with the help of bile salts produced by the liver?

Vitamins A, D, E, and K Signup and view all the answers

Which of the following plasma proteins is synthesized by the liver and plays a crucial role in blood clotting?

Fibrinogen Signup and view all the answers

Which liver function involves detoxifying both endogenous and exogenous compounds?

Metabolism of toxins Signup and view all the answers

The liver serves as a buffer between the gut and the rest of the body by performing which function?

Immune functions Signup and view all the answers

Which of the following describes the liver's role in intermediary metabolism?

Storage of glycogen and fats Signup and view all the answers

Which of the following functions is performed by the liver in the fetus and infants but not in adults?

Haematopoiesis Signup and view all the answers

What role does the liver play in bile formation?

It produces bile salts for fat digestion and excretes bilirubin. Signup and view all the answers

Chronic passive venous congestion is most marked around which liver structure?

Central hepatic vein branches Signup and view all the answers

What factor primarily determines the outcome of acute liver damage?

Degree of liver damage Signup and view all the answers

If acute liver damage is transient and does not lead to acute liver failure, what is the most likely outcome?

Recovery Signup and view all the answers

Chronic liver damage is defined as liver injury persisting for how long?

More than 6 months Signup and view all the answers

Which of the following is a potential consequence of ongoing liver injury?

Cirrhosis with fibrosis Signup and view all the answers

Which pattern of liver cell death involves the death of large groups of hepatocytes?

Bridging necrosis Signup and view all the answers

Which of the following best describes apoptosis in the liver?

Single cell death Signup and view all the answers

Massive hepatic necrosis refers to which type of liver injury?

Widespread death of hepatocytes Signup and view all the answers

Which of the following is an example of direct cytotoxic damage to the liver?

Drug-induced liver injury Signup and view all the answers

Which type of liver injury is characterized by hepatocytes being perceived as antigenic, often seen in autoimmune hepatitis?

Antigenic cell injury Signup and view all the answers

Damage to hepatocytes rendered antigenic by hepatitis B virus (HBV) is an example of which type of injury?

Antigenic cell injury Signup and view all the answers

Which of the following outcomes is most likely if acute liver damage is extensive?

Acute liver failure Signup and view all the answers

Which of the following conditions is indicative of chronic liver damage?

Liver disease persisting for more than 6 months Signup and view all the answers

Which of the following statements is true regarding the regenerative capacity of the liver?

The liver has a significant capacity for regeneration unless the damage is extensive. Signup and view all the answers

What is the primary difference between acute and chronic liver damage?

Chronic damage involves prolonged injury lasting over 6 months, while acute damage is short-term. Signup and view all the answers

What is the potential consequence of liver fibrosis progressing without intervention?

Cirrhosis Signup and view all the answers

What role does the ATP7B gene play in Wilson's disease?

It codes for a protein that helps in copper transport. Signup and view all the answers

What is the primary cause of Primary Biliary Cholangitis as indicated by the presence of Antimitochondrial Antibody (AMA)?

Autoimmune response Signup and view all the answers

Study Notes

Overview Of Liver Disease

Liver disease is an increasing cause of morbidity and mortality, contributing to lost life years.
While less common than heart disease, cancer, and stroke, it is still a significant health issue.
Liver disease is managed by gastroenterologists, some specialize as hepatologists.
Surgeons handle cases of gallstones, pancreatitis, and sometimes extrahepatic biliary tract disease.
General Practitioners (GPs) typically manage abnormal liver blood tests.
The patterns of liver disease vary depending on the geographical location.
Cirrhosis can be caused by alcohol or chronic viral diseases like Hepatitis B (HBV).
Liver tumors can be metastases from other cancers, such as pancreatic cancer, or primary hepatocellular carcinoma.

Causes Of Liver Damage

Alcohol consumption can lead to liver damage.
Non-alcoholic fatty liver disease (NAFLD) is often associated with metabolic syndrome, including type 2 diabetes and obesity.
Viral infections, including Hepatitis A, B, C, and E, can cause acute or chronic liver disease.
Certain medications can damage the liver.
Autoimmune disorders can affect the liver.
Inherited metabolic disorders, such as hemochromatosis (HFE gene), Wilson's disease, and alpha-1 antitrypsin deficiency (A1AT def) are also causes.
Vascular conditions, such as congestion or ischemia, can impact the liver.
Chronic biliary disease, where retained bile salts damage the liver is another cause.

Liver Structure

The liver is a large organ weighing approximately 1.5 kg.
It has a substantial functional reserve and a stable cell population capable of regeneration.
The liver has a limited repertoire of responses to acute and chronic injury.
Understanding the history, examination, and diagnostic tests is critical.
Various causes of injury can interact with each other.

Normal Liver

The gross appearance of a healthy liver can be used as a comparison point.
The liver receives blood from two sources: the hepatic artery and the portal vein.
Blood flows through sinusoids, spaces separating plates of hepatocytes (liver cells).
Sinusoids are lined by fenestrated endothelium and macrophages (Kupffer cells).
The Space of Disse, located between sinusoids and hepatocytes, contains hepatic stellate cells.
Blood drains from the hepatic vein into the inferior vena cava (IVC), and then to the right ventricle (RV) of the heart.

Hepatic Stellate Cells

These cells are located in the Space of Disse, a space between the sinusoids and hepatocytes.
They are responsible for storing vitamin A and producing extracellular matrix proteins, which are important for maintaining liver structure.
In response to liver injury, they can undergo activation, leading to increased collagen production and fibrosis.

Liver Plates

Liver plates are like plates in a dishwasher. They are arranged to allow free flow of fluid.
The arrangement of the plates allows blood to flow effectively from the portal tract through the sinusoids to the hepatic venule.

Liver Structure - Space of Disse

This is a space between the sinusoids and hepatocytes that contains hepatic stellate cells.
Important for liver function and for the exchange of nutrients and waste products between hepatocytes and the blood.
It is also a site of inflammation and fibrosis in liver disease.

Portal Tracts

These are the smallest branches of the portal vein, hepatic artery, and bile duct.
They are located within the liver parenchyma, and a distinct interface exists between the portal tract and the surrounding liver tissue.

Bile Drainage

Bile is produced by hepatocytes and secreted into canaliculi, small channels between hepatocytes.
These small ductules form from the canaliculi and join to form small ducts within the portal tracts.
The left and right hepatic ducts merge to form the common hepatic duct.
The common hepatic duct joins the cystic duct to form the common bile duct.
In about 75% of cases, the common bile duct and pancreatic duct join at the ampulla.
The gallbladder serves as a storage reservoir for bile.

Liver Micro-Anatomy

The acinus is the preferred concept for describing the functional unit of the liver, centered around portal tracts.
An acinus encompasses hepatocytes and sinusoids from two adjacent lobules supplied by one portal tract.
The acinus helps to explain patterns of liver damage, with ischemic/toxic injury most severe in zone 3.
The concept of the acinus allows for a precise description of damage and fibrosis patterns.

Vascular Injury To The Liver

Chronic (passive) venous congestion of the liver is often associated with right heart failure (e.g., cor pulmonale, mitral stenosis), and most prominent in cases of tricuspid incompetence and constrictive pericarditis.
Mild elevation of liver blood tests (ALT, AST) is seen.
Obstruction to venous outflow from the liver (hepatic vein/IVC) leads to Budd Chiari syndrome.
Liver infarction is very rare.
Ischemic injury to the liver ("ischemic hepatitis", "shock liver") is associated with hypoperfusion, hypotension/shock/circulatory failure.
Marked elevation of liver blood tests (ALT, AST) occurs.
Outcome depends on the underlying cause.
Susceptibility to ischemic injury is increased by passive venous congestion or cirrhosis.

Normal Liver - Gross Appearance

For comparison, the gross appearance of a healthy liver is provided.

Chronic Passive Venous Congestion Of Liver

Gross appearance: The liver exhibits a "nutmeg liver" appearance.
Congestion is most evident around central hepatic vein branches.

Liver Function

The liver synthesizes most plasma proteins.
It plays a role in clotting.
Bile production is a key function.
Bile excretion removes bilirubin.
Bile salts are responsible for digestion of fats and fat-soluble vitamins (A, D, E, and K).
Detoxification of endogenous and exogenous compounds occurs.
The liver is involved in intermediary metabolism, altering and storing various substances.
It plays a role in immune function.
The liver acts as a buffer between the gut and the rest of the body.
It stores normal and abnormal substances.
In fetuses and infants, the liver is involved in hematopoiesis (blood cell production).

Damage To The Liver

Acute Liver Damage

The liver has a reserve and regenerative capacity.
Outcomes depend on the degree of damage.
Extensive damage can lead to acute liver failure.
Transient and non-life-threatening damage usually leads to recovery.
Ongoing or repeated insults can result in chronic damage.

Chronic Liver Damage

If liver insults persist, chronic liver disease develops (defined as >6 months).
Fibrosis develops, with increasing severity leading to cirrhosis.
Different causes of liver damage can coexist, be superimposed, or potentiate each other.

Damage To The Liver Continued

Different patterns of cell damage and death can occur.
Cell injury can be reversible or irreversible.
Triggers of injury can vary.
Damage can be direct (cytopathic/cytotoxic/ischemic) or indirect.
Hepatocytes can become antigenic, as seen in HBV infection.
Cells can be perceived as antigenic, as in autoimmune hepatitis.
The degree of injury can range from single cell death (apoptosis) to massive hepatic necrosis.

Assessment Of Liver Damage

Inflammation and necrosis: The extent of inflammation and necrosis is graded.
The location of inflammation is important: portal/periportal or lobular (parenchymal).
Interface inflammation is known as "piecemeal necrosis."
The pattern of portal/periportal damage is considered.
The presence and type of necrosis (single cells, spotty, bridging) is evaluated.
The predominant inflammatory cell type is identified.
The type of inflammatory cell depends on the etiology, not just the duration of the disease.

Assessment Of Liver Damage Continued

Fibrosis: The degree and extent of fibrosis is "staged."
Different types of fibrosis include:
- Portal fibrosis
- Periportal fibrosis
- Bridging fibrosis
- Cirrhosis
Liver biopsy involves complex scoring systems to assess grade and stage independently.

Stages Of Liver Fibrosis: Trichrome Stain

Fibrous tissue appears blue due to the trichrome stain.

Definition Of Cirrhosis

Cirrhosis is characterized by diffuse distortion of the liver architecture.
Fibrous bands/septa surround regenerative nodules.
Vascular relationships are distorted.
Portal hypertension develops as a consequence of cirrhosis.
The functional capacity of the liver is reduced.
An increased risk of hepatocellular carcinoma exists.

Cirrhosis

Cirrhosis is the end-stage of chronic liver disease, resulting from ongoing damage.
The liver's reserve is diminished.
Vascular changes associated with cirrhosis: - Obliteration/thrombosis of veins within the liver - Formation of collateral channels/shunts within the liver - Sinusoids become "capillarised" (lose fenestrations) - Hepatic venous pressure gradient (HVPG) rises

Cirrhosis: Gross (Macroscopic) Appearance

The gross appearance of a cirrhotic liver is provided.

Normal Liver: Histology For Comparison

Normal liver histology is shown for comparison, using hematoxylin and eosin (H&E) staining.

Cirrhosis: Histology, H&E

Diffuse architectural distortion, regenerative parenchyma nodules separated by fibrous bands.

Cirrhosis: Trichrome Stain

The trichrome stain highlights fibrous tissue in blue.

Portal Hypertension In Cirrhosis

Increased resistance to portal blood flow in the liver leads to rising HVPG.
Increased splanchnic vasodilation (via.NO), increasing portal blood flow, contributes to portal hypertension.
Splanchnic vasodilation lowers total peripheral resistance (TPR) and blood pressure.
A compensatory increase in cardiac output leads to a hyperdynamic circulation in cirrhosis.
Splanchnic vasodilation triggers compensatory mechanisms.

Portal Hypertension In Cirrhosis: Simplified

Increased blood supply to the intestines due to splanchnic vasodilation.
More blood enters the intestines, causing increased pressure in the portal system.
The blocked liver in cirrhosis restricts blood flow, further increasing pressure in the portal system.

Portal Hypertension, Ascites, And HRS

Compensation for widespread vasodilation involves activation of the renin-angiotensin-aldosterone system and stimulation of ADH secretion.
Sodium and water retention occurs.
Reflex renal vasoconstriction reduces perfusion and glomerular filtration rate, increasing the risk of hepatorenal syndrome (HRS).

Portal Hypertension, Ascites, And HRS Continued

Ascites:
- Sodium and water retention occur in the setting of portal hypertension.
- Fluid preferentially accumulates in the peritoneal cavity.
- Fluid leakage from peritoneal vessels occurs.
- Higher mean hydrostatic pressure due to portal hypertension.
- Lower oncotic pressure to keep fluid in, due to low albumin levels.

Portal Hypertension & Shunts

Attempts to decompress portal hypertension lead to the development of collaterals:
- Intrahepatic porto-systemic shunts/collaterals
- Extrahepatic porto-systemic anastomoses dilate
- Therapeutic insertion of a transjugular intrahepatic porto-systemic shunt (TIPS)
"Shunted" blood bypasses the liver, reducing liver function (increasing HE risk), exacerbating sinusoid "capillarisation", and decreasing liver perfusion.

Compensated Versus Decompensated Cirrhosis

Compensated Cirrhosis

May or may not have biochemical/radiological abnormalities.
May or may not have signs of chronic liver disease/portal hypertension.
May or may not have varices on OGD (gastroscopy).
Can be a potentially unstable state, as further injury may trigger decompensation.
Factors that can precipitate decompensation: infection, bleeding, hypotension, alcohol, medication, dehydration, trauma, surgery.

Compensated Versus Decompensated Cirrhosis Continued

Decompensated Cirrhosis

Development of key complications:
- Ascites (may become refractory to treatment)
- Hepatic encephalopathy
- Variceal hemorrhage
- Hepatorenal syndrome (HRS)
- Jaundice
- Infection (esp. spontaneous bacterial peritonitis)
- Hepatocellular carcinoma

Compensated Versus Decompensated Cirrhosis Continued

Prognosis is significantly impacted by decompensation:
- 1-year mortality for compensated cirrhosis is 1%.
- 1-year mortality for compensated cirrhosis with varices is 4%.
- 1-year mortality for decompensated cirrhosis with ascites is 20%.
- 1-year mortality for decompensated cirrhosis with other features is greater than 50%.

Decompensation Affects Prognosis

A visual representation of the progression of chronic liver disease and the impact of decompensation on survival.

Natural History Of Chronic Liver Disease: Summary

A graphic showing probability of survival based on cirrhosis stage.

Changing Concepts Of Cirrhosis: New

Progression of cirrhosis is not inevitable, and treatment can induce regression of structural changes.
Fibrosis is dynamic, and ongoing damage can be modified.
The etiology is crucial for management.
Active management is essential for early diagnosis, limiting progression, and preventing complications.
"Advanced stage of chronic liver disease" should include advanced fibrosis and potentially replace the term "cirrhosis."
Decompensation, when HVPG reaches a critical threshold, becomes the inevitable end stage.

Presentation Of Liver Disease

Patients can be asymptomatic or experience mild nonspecific symptoms, or have an at-risk history.
Liver disease might be identified through liver blood tests or imaging studies.
Symptoms or signs that can indicate liver disease (e.g., jaundice) can be present:
- Acute liver disease (short of acute liver failure)
- Acute flare or exacerbation of chronic disease
- End-stage chronic liver disease (cirrhosis)
Acute liver failure may occur.
Decompensation of cirrhosis can manifest with major complications.

End Of Lecture

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