SysPath: GI Path 3 (Cirrhosis, Jaundice, Hepatitis)

• Major diseases of the liver include hepatitis, MASLD (formerly NAFLD), hepatocellular carcinoma (HCC), and liver failure.
• Hepatitis can be viral, alcoholic, or chronic

Broad Categories of Hepatic Injury

• Abnormal liver conditions are usually caused by damage from the diseases mentioned.
• These conditions include cirrhosis, portal hypertension, esophageal varices, and hepatic encephalopathy.
• Liver disease complications often stem from secondary conditions

Cirrhosis

• Cirrhosis is an irreversible replacement of normal liver tissue and is replaced with non-functional scar tissue.
• Alcoholic hepatitis is the most common cause of Cirrhosis.
  • This is due to liver inflammation from excessive alcohol consumption.
• Other causes of cirrhosis includes viral hepatitis (Hep B & C) and metabolic dysfunction-associated steatotic liver disease (MASLD).
• Cirrhosis is twice as common in males.
• Autopsies in the US reveal that 5% of the population has cirrhosis.
• Cirrhosis results in 25,000 deaths per year in the US.
• Patients usually die within 5-15 years without a transplant due to complications.

Complications of Cirrhosis

• Portal hypertension can cause additional complications which include:
  • Esophageal varices
  • Mass hematemesis
  • Rectal varices
  • Ascites
  • Kidney failure
  • Hepatic encephalopathy
• Cirrhosis causes a decrease in bile production, which decreases vitamin D absorption, and can lead to osteoporosis.
• Poor vitamin K absorption occurs with cirrhosis resulting in a tendency for bleeding.
• Platelets can get trapped in the spleen due to splenomegaly, resulting in a tendency for bleeding which can lead to anemia.

Signs and Symptoms of Cirrhosis

• Many people may have no signs or symptoms for several years.
• Recognizable symptoms fall into 2 categories:
  • Symptoms related to portal hypertension.
  • Symptoms related to declining liver function.
• The most common symptoms include weakness, malaise, fatigue, weight loss, ascites, and loss of appetite.
• Symptoms related to declining liver function include:
  • Reduction in bile production which results in decreased absorption of fat and fat-soluble vitamins.
  • Greasy, foul smelling steatorrhea
  • Fatigue, loss of appetite, loss of weight
  • Dark urine
  • Generalized edema
  • Malabsorption
• Symptoms related to portal hypertension:
  • Jaundice
  • Ascites
  • Hepatomegaly and splenomegaly
  • Digital clubbing
  • Caput medusae, spider telangiectasia
  • Small yellow nodules around the eyes (xanthelasma)

Symptoms in Detail

• Spider telangiectasia (spider angioma) has an unclear pathogenesis and it's possibly related to an elevation in vascular endothelial growth factor and fibroblast growth factor or an altered estrogen/testosterone ratio.
• Digital clubbing also has an unclear pathogenesis.
• Caput medusae is caused be swollen veins around the umbilicus due to portal hypertension.
• Xanthelasma is benign yellow growths that appear on or by the corners of your eyelids due to cholesterol deposits buildup under the skin with dyslipidemia, altered lipoprotein profiles, altered fat metabolisms, and association with metabolic disease.
• Other cirrhosis symptoms include:
  • Sarcopenia (muscle atrophy)
  • Palmar erythema
  • Gynecomastia, testicular atrophy, and thinning of armpit hair
  • Dupuytren's contracture, which is fibrosis of the palmar aponeurosis and the exact mechanisms linking cirrhosis is not fully understood

Cirrhosis Diagnosis and Treatment

• It consists of a review of the patient Hx, SSx, PE, and blood tests.
• The liver feels nodular and firm on palpation.
• Confirmation is made through advanced imaging (US or CT), or a biopsy.
• Blood tests determine liver function (LFTs):
  • Liver enzymes are elevated (AST and ALT)
  • Elevated bilirubin, decreased albumin
  • CBC may show signs of anemia
  • Blood work can determine underlying cause (hep B and hep C serology)
• Treatment is:
  • Eliminating alcohol, especially with alcoholic hepatitis.
  • Improving diet and activity, if caused by metabolic disease.
  • Reviewing medications (Rx and OTC) and supplements with a GP for liver processing.
  • Diuretics
  • Low sodium diet
  • Liver transplant for liver failure (80-90% liver destruction).
• Massage is safe, but is not indicated for cirrhosis.

Portal Hypertension

• Portal hypertension is defined as abnormally high blood pressure in the branches of the portal vein.
• It presents as:
  • And enlarged abdomen
  • Abdominal discomfort
  • Confusion
  • Internal Bleeding.
• Is caused by Cirrhosis, scarring leads to decreased blood flow through the liver, Thrombosis, parasitic infections called schistosomiasis or malignancy.

Signs and Symptoms of Portal Hypertension

• The portal hypertension itself does not cause symptoms, but it creates consequences that do. It presents with:
  • Ascites
  • Telangiectasia and caput medusae
  • Esophageal varices
  • Mass hematemesis
  • Splenomegaly
  • Hepatic encephalopathy
  • Confusion
  • Coma
  • Gastrointestinal bleeding
• Diagnosis includes patient symptoms, health history and physical examination and confirmed with US.
• Treatment is:
  • Mostly irreversible, as it's caused by cirrhosis.
  • Medications to reduce portal BP (beta blockers) can be used
  • If bleeding occurs, emergency treatment is required such as surgery to reduce bleeds, or Bypass shunt.
• Massage is not indicated for portal hypertension

Esophageal Varices

• Esophageal varices are engorged, tortuous, and fragile varicose vessels of the lower Esophagus
• Are caused by portal hypertension, where retrograde flow into the lower esophageal vessels causes distention and varices.
• Diagnosis: Hematamesis, black, tarry, or bloody stools, and lightheadedness due to blood loss
• Treatment:
  • Reduce blood pressure,
  • Medical Emergency
  • Endoscope to confirm bleeding is from varices or banding off/chemical injections.
  • Vasopressin IV to constrict bleeding veins or transfusion to replace loss.
• Massage is not indicated for esophageal varices, as it is possibly contraindicated.

Hepatic Encephalopathy

• Hepatic encephalopathy is brain function deterioration due to buildup of toxic substances not normally removed by the liver.
• This can be cause by portal hypertension or liver failure, and can be trigged by an alcohol binge, drug intake, or liver stressors in those with longstanding liver disorders
• Signs and Symptoms include:
  • Decreased alertness and increased confusion,
  • Subtle changes in logical thinking, judgment, mood, personality, and behavior.
  • Drowsiness, confusion, and disorientation.
  • Asterixis
  • Sluggish movements
  • Speech
• Uncommon agitation or seizures occur in the late stages, and it eventually leads to a loss of consciousness and coma.
• Diagnosis is done by:
  • Patient symptoms, Hx, and a physical examination,
  • A CT scan and EEG as well as Blood tests for liver function and presence of ammonia.
• Treatment is:
  • Identifying and eliminate triggers,
  • Reducing protein intake and reducing lactulose sugar in diet to help decrease blood ammonia.
  • Liver treatment
• Prognosis:
  • Possible complete recovery, chronic liver failure predisposes to future episodes and can be fatal in > 50% of cases.
  • Fatal in 80% of people who fall into coma

Jaundice

• Jaundice occurs when excess bilirubin circulates and dissolves in subcutaneous fat (the fat just beneath the skin) causing a yellowish appearance in the skin and whites of the eyes.
• Etiology:
  • Preheptic is conditions the affect the blood's rate of breaking down red blood cells.
  • Intrahepatic is when the Liver tissue is less effective at filtering out bilirubin.
  • Postheaotic is when the bilirubin filter cannot drain due obstructions.
• Yellow skin and sclera, yellow colour inside the mouth and dark or brown-coloured urine, pruritis and pale stools.
• Treatment may or may not be indicated based on the cause and severity

Hepatitis

• Hepatitis involves liver inflammation that can have a variety of causes such as viral infections, excessive alcohol use, autoimmune disorders, toxin exposure or with drugs.
• The types of hepatitis:
  • Viral hepatitis from A-E
  • Alcoholic hepatitis from overconsumption of EtOH
• Both lead to chronic hepatitis characterized by unrelenting liver inflammation.

Acute Viral Hepatitis

• Inflammation of the liver due to infection with one of the five hepatitis viruses (A-E).
• The Hepatitis A virus is the most common cause of acute viral hepatitis followed by Hepatitis B and C.
• Hepatitis D and E are rare
• It presents with a Sudden onset with a short duration (weeks) and symptoms can range from none to severe:
  • N/V, poor appetite, fever, RUQ pain, and jaundice are common
• No specific treatment necessary for hep A, B, and E, and antiviral treatments are available for hep C and hep D.
• Hep C has the highest risk of turning chronic and Hep D needs hep B for it to be contracted.
• There are vaccines for hep A and B but hep E only has one in china and not approved in US or Canada.
• Severity depends on instigating virus and the host response.
  • Hep A and C can be mild.
  • Hep B and E are more severe, with mortality of Hep B and D is at its highest mortality
• Common Signs and Symptoms: sudden onset include Prodromal symptoms poor appetite, and joint pain.

Hepatitis A specifics

• Hepatitis A is transmitted through fecal-oral routes such as poor hygiene, shellfish, contaminated water or blood.
• Its rare in Canada, has a 2-6 weeks Incubation and is asymptomatic. Also can can cause a complete recovery, no Chronic hepatitis, mild fever and vomiting.
• Should be avoided with hand washing and receiving vaccines of Twinrix

Hepatitis B specifics

• Hepatitis B transmission happens with bodily fluids during sexual relations, recreational drugs use. It is more common in Africa and the Caribbean.
• Has an incubation of 40-180 days, with joint paints and fever.
• Has vaccines for everyone under 18, and avoiding needles.

Hepatitis C specifics

• Is transmitted with blood with blood.
• Chronic infection results in 75% of cases .
• Is recommended to avoid high risk behavior

Hepatitis D and E specifics.

• Viral hepatitis D can only present when you have Hepatitis B, it causes worse symptoms and illness
• Hepatitis E is a fecal-oral transmission, and is dangerous for pregnant woman

Viral Hepatitis

• Viral hepatitis massage is not indicated with a fever that's without the use of antipyretics