Liver Cirrhosis PDF

LIVER CIRRHOSIS Dr. Mu’taz M Massad Assistant Professor Faculty of Medicine -Hashemite university  Cirrhosis represents a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture and the formation of regenerative nodules. It...

LIVER CIRRHOSIS Dr. Mu’taz M Massad Assistant Professor Faculty of Medicine -Hashemite university  Cirrhosis represents a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture and the formation of regenerative nodules. It is generally considered to be irreversible in its advanced stages, at which point the only treatment option may be liver transplantation.  ETIOLOGIES AND CLASSIFICATION Nonalcoholic fatty liver disease Chronic viral hepatitis (hepatitis B, C) Alcoholic liver disease Hemochromatosis Less common causes include: Autoimmune hepatitis Primary and secondary biliary cirrhosis Primary sclerosing cholangitis Medications (eg, methotrexate, isoniazid) Wilson disease Alpha-1 antitrypsin deficiency Celiac disease Idiopathic adulthood ductopenia Granulomatous liver disease Idiopathic portal fibrosis Polycystic liver disease Infection (eg, brucellosis, syphilis, echinococcosis) Right-sided heart failure Hereditary hemorrhagic telangiectasia Veno-occlusive disease  CLINICAL MANIFESTATIONS clinical manifestations of cirrhosis may include : Nonspecific symptoms (eg, anorexia, weight loss, weakness, fatigue) or signs and symptoms of hepatic decompensation (jaundice, pruritus, signs of upper gastrointestinal bleeding, abdominal distension from ascites, confusion due to hepatic encephalopathy) ask about sleep disturbance & chronic diarrhea. The cause of diarrhea in patients with cirrhosis may be multifactorial (eg, alterations in small bowel motility, small bowel bacterial overgrowth, changes in intestinal permeability and bile acid deficiency)  In women, chronic anovulation is common, which may manifest as amenorrhea or irregular menstrual bleeding.. Men with cirrhosis may develop hypogonadism. It is manifested by impotence, infertility, loss of sexual drive, and testicular atrophy. predominantly in patients with alcoholic cirrhosis and hemochromatosis.  PHYSICAL SIGNS Decreasing blood pressure Skin findings Jaundice ( yellow coloring of the skin and mucous membranes that results from increased serum bilirubin. : detectable if > 2 to 3 mg/dL. excessive consumption of carotene vs jaundice. Spider angiomata (also referred to as spider telangiectasias)  Head and neck findings : Parotid gland enlargement and fetor hepaticus. Chest : gynecomastia & spider angiomata. Abdominal findings: splenomegaly, ascites, caput medusae, and a Cruveilhier-Baumgarten murmur. Genitourinary findings: testicular atrophy due to the development of hypogonadism. Extremity findings : palmar erythema, nail changes, clubbing, hypertrophic osteoarthropathy, and Dupuytren's contracture & L.L edema Copyrights apply  Physical examination findings may include jaundice, spider angiomata, gynecomastia, ascites, splenomegaly, palmar erythema, digital clubbing, and asterixis. Laboratory abnormalities may include elevated serum bilirubin, abnormal aminotransferases, elevated alkaline phosphatase/gamma-glutamyl transpeptidase, a prolonged prothrombin time/elevated international normalized ratio (INR), hyponatremia, hypoalbuminemia, hypoglycemia, and thrombocytopenia. CHILD PUGH SCORE Copyrights apply  Radiologic findings : Abd. ultrasound, CT scan, and MRI Findings may include a liver that appears shrunken, irregular, and nodular. Imaging studies may also show evidence of varices and ascites in patients with portal hypertension.  DIAGNOSIS patients suspected of having cirrhosis, abdominal imaging (typically ultrasound) is obtained to evaluate the liver parenchyma and to detect extrahepatic manifestations of cirrhosis. A liver biopsy is required to definitively confirm the diagnosis. However, it is generally not necessary if the clinical, laboratory, and radiologic data strongly suggest the presence of cirrhosis and the results would not alter the patient's management. Noninvasive serologic ( AST / plts ratio , FibroTest/FibroSure ) and radiographic (Elastography , nuclear studies ) methods for diagnosing cirrhosis are also being developed.  COMPLICATIONS OF CIRRHOSIS & PORTAL HYPERTENSION Ascites : SAAG Treatment Spontaneous bacterial peritonitis Definition Treatment Hepatic Encephalopathy Grades Precipitating factors Treatment  Hepatorenal syndrome. Diagnostic criteria: Types Treatment.  Portopulmonary Hypertension Diagnostic criteria Echocardiogram is the screening test of choice. Treatment: O2 , diuretics. Vasodilators.  Hepatopulmonary syndrome Definition: Hypoxemia in pt. with liver disease & portal HTN resulting from increase A-a gradient. Diagnostic criteria : Platypnea & Orthodeoxia  Diagnosis : Pao2