Liver Cirrhosis (2020) PDF

 Chronic liver disease refers to disease of the liver which lasts over a period of six months. Progressive destruction of the liver parenchyma over a period greater than 6 months leading to fibrosis and cirrhosis What is cirrhosis? Cirrhosis is a condition where normal liver tissue is rep...

 Chronic liver disease refers to disease of the liver which lasts over a period of six months. Progressive destruction of the liver parenchyma over a period greater than 6 months leading to fibrosis and cirrhosis What is cirrhosis? Cirrhosis is a condition where normal liver tissue is replaced by scar tissue (fibrosis). The 'scarring' tends to be a gradual process (the disease develops slowly over years). The scar tissue affects the normal structure and regrowth of liver cells. Liver cells become damaged and die as scar tissue gradually develops. Therefore, the liver gradually loses its ability to function well. The scar tissue can also affect the blood flow through the liver which can cause back pressure in the blood vessels which bring blood to the liver. This back pressure is called portal hypertension. The fibrosis causes distortion of the hepatic vasculature and can lead to an increased intrahepatic resistance and portal hypertension. Portal hypertension can lead to oesophageal varices. Damage to liver cells (hepatocytes) causes impaired liver function and the liver becomes less able to synthesis important substances such as clotting factors and is also less able to detoxify other substances (Liver Failure). Definition of cirrhosis It is a chronic progressive diffuse irreversible disease of the liver. It is characterized by necrosis, fibrosis, regenerating nodules and distortion of hepatic architecture. Causes of liver cirrhosis Viral hepatitis: - Cirrhosis is most commonly caused by hepatitis B and hepatitis C. - These viruses may lead to chronic hepatitis is inflammation of the liver. Left untreated, it can damage the liver over many years, eventually resulting in cirrhosis. Alcoholic cirrhosis: - Alcoholic cirrhosis develops in individuals who drink heavily for a decade or more. Alcohol seems to injure the liver by blocking the normal metabolism of protein, fats and carbohydrates. Causes of liver cirrhosis (Cont.) Non-alcoholic steatohepatitis: - Non-alcoholic steatohepatitis (NASH) is a severe liver condition that can lead to cirrhosis. As with alcohol-related liver disease, the early stage of NASH is the build-up of excess fat in the liver. This fat is associated with inflammation and scarring, which could lead to cirrhosis. - NASH can develop in people who are obese, have diabetes, have high levels of fat in the blood (high cholesterol) and high blood pressure. - Most people with NASH feel well and aren't aware they have a problem until cirrhosis occurs and liver function is affected. Causes of liver cirrhosis (Cont.) Cryptogenic cirrhosis: Cryptogenic cirrhosis refers to cirrhosis of the liver of unknown origin. Earlier data indicated that this condition represented approximately 10% of all cases of cirrhosis. However, most of these cases were likely due to Non-Alcoholic Fatty Liver Disease (NAFLD). Causes of liver cirrhosis (Cont.) Autoimmune hepatitis: The immune system normally makes antibodies to attack bacteria, viruses and other germs. In people with autoimmune diseases, the immune system makes antibodies against part(s) of the body. Something triggers the immune system to make these autoantibodies but the trigger is not known. In autoimmune hepatitis, the immune system makes antibodies against liver cells, which can lead to damage and cirrhosis. Causes of liver cirrhosis (Cont.) Metabolic disorders – such as: - haemochromatosis (a build-up of iron in the liver and other parts of the body) a - Wilson's disease (a build-up of copper in the liver and other parts of the body) biliary obstruction i.e. any condition that causes the bile ducts to become blocked – such as cancer of the bile ducts or pancreatic cancer. Damage to the bile ducts, which function to drain bile: One example of such a condition is primary biliary cirrhosis. Budd-Chiari syndrome – caused by blood clots blocking the veins that carry blood from the liver Drugs and toxins including methotrexate, amiodarone and isoniazid, acetaminophen Congestive heart failure (long standing). Clinical picture of liver cirrhosis No symptoms in the early stages of the disease. As the disease progress, fibrosis and cell injury occurs, and liver function starts to fail and a person may experience exhaustion, fatigue, loss of appetite, nausea, weakness, weight loss…..etc With more advanced disease, complications may develop. In some people, complications may present as the first sign of the disease.  Complications of liver cirrhosis Portal hypertension Liver cell failure Hepatorenal syndrome Encephalopathy Hepatocellular carcinoma. Complications of Liver Cirrhosis (1) Portal hypertension: results in: Spleenomegaly. Ascites Opening of portosystemic collateral resulting in: Esophageal varices in the lower 1/3 of the esophagus, when it bleeds, it leads to hematemesis which may be recurrent and sever. Complications of Liver Cirrhosis (Cont.) (2) Liver cell failure: General failure of health: weakness, easy fatigue and loss of flesh. Jaundice: hepatocellular jaundice due to defective conjucation & excretion of bilirubin. Foetor hepaticus: sweetish slightly foecal smell, due to liver cell disease and extensive collaterals. Hypoalbuminemia: liver loses its ability to synthesis albumin. Hypoalbuminemia leads to edema of lower limbs and ascites. Bruising and bleeding: diminished production of prothrombin and vitamin K dependent coagulation factors by the liver. Palmar erythema: reddening of palms at the thenar and hypothenar eminences. Spider angiomata or spider nevi (dialated subcutaneous vessels) are vascular lesions consisting of a central arteriole surrounded by many small vessels , hence the name “spider”. Endocrinal changes in males due to excess estrogen, normally catabolized in the liver leading to: Loss of musculine (male) hair distribution, gynaecomastia (enlargement of male breast), testicular atrophy….etc Complications of Liver Cirrhosis (Cont.) (3) hepatic encephalopathy (hepatic coma): A damaged liver cannot remove toxins from the blood , resulting in accumulation of toxic nitrogenous substances (e.g. ammonia) (normally inactivated by the liver) in the blood and eventually in the brain , leading to disturbed brain function. - Personality changes, hypersomnia, disturbed sleep rhythm. - Inability to concentrate, irritability. - Drowsiness. - Flapping tremors. - Later patient may develop deep coma (hepatic coma).  Investigations Non-invasive investigations: Laboratory tests. Radiological studies. Invasive investigations: Upper GI endoscopy (for esophageal varices and other associated conditions e.g gastritis, ulcer…etc). Biopsy.  Non-invasive investigations (1)Laboratory tests Serum enzymes : AST (Aspartate amionotransferase) and ALT (Alanine aminotransferase) are liver enzymes that are raised when there is liver injury or inflammation. Liver enzymes may be raised in both alcoholic and non-alcoholic fatty liver diseases. GGT (Gamma glutamyl transferase) and Alkaline Phophatase are also enzymes that are released from bile ducts and are raised in liver diseases. Blood levels of bilirubin rise in liver disease. Estimation of both conjugated and unconjugated forms of this bile in blood is indicative of different liver diseases. Blood levels of protein and albumin are indicative of healthy functioning of the liver. In liver disease there is derangement of these levels.  Routine blood tests like complete blood count (CBC) may also be helpful in liver disease estimation. Total blood counts of White blood cells, red blood cells and platelets may be reduced in advanced liver disease where there is suppression of bone marrow that is the seat of production of these cells  Non-invasive Investigations (2)Radiological investigations Ultrasonogram or USG of the abdomen – This uses sound waves to detect liver pathology. This is useful, inexpensive and a noninvasive method to diagnose several conditions. It is most commonly used to detect gall bladder stones and other pathologies. An USG with Doppler can also look at the blood flow in the portal venous system and diagnose obstructions and portal hypertension. CT scan – Computed Axial Tomographical image or scan can be used to look at deeper tissues within the liver in detail to diagnose several liver disease conditions. MRI or magnetic resonance imaging is a clearer imaging study to look at the damaged liver tissues for clues regarding pathology. ERCP (Endoscopic retrograde cholangiopancreatography) – In this procedure a long thin tube, called an endoscope, that has a camera at its tip is guided into the gastrointestinal tract to look at the bile and pancreatic ducts. Any pathology in these tracts can be detected. ERCP can be used in diagnosis of tumors, gall bladder stones and obstructions, cysts etc.  Invasive investigations (1) Upper gastrointestinal endoscopy: It is a diagnostic and therapeutic procedure for esophageal varices. (2) Liver Biopsy This procedure involves using a long thin needle to aspirate bits of tissues of the liver under a local anesthetic agent. The needle is guided into the liver with the help of either USG or CT scan. This is used to confirm the diagnosis. The aspirated material is examined under the microscope.