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CIRRHOSIS OF LIVERCIRRHOSIS OF LIVERDr. Mizanur Rahman Chowdhury
EpidemiologyEpidemiology40% cases asymptomaticIt is the 12thleading cause of death inUnited States.Approximately 30,000...
CirrhosisCirrhosisDefinition: It is the end stage of liverdisease characterized byBridging fibrous septa in the form ofde...
Normal LiverNormal Liver
Normal Liver HistologyNormal Liver HistologyCVPT
Histological classificationHistological classificationMicronodular Cirrhosis :Thickregular septa and regenerating smallnod...
Histological classificationHistological classificationMicronodular Cirrhosis
Micronodular cirrhosis:Micronodular cirrhosis:
Histological classificationHistological classificationMacronodular Cirrhosis :Septaand nodules of variable size andnormal ...
Histological classificationHistological classificationMacronodular Cirrhosis
Histological classificationHistological classificationMacronodular Cirrhosis
Aetiological classificationAetiological classificationViral: Chronic Hepatitis B, Hepatitis Cinfection.AlcoholNon alcoh...
Aetiological classificationAetiological classificationProlong cholestasisHepatic venous outflow obstruction:Constrictive...
Etiology of CirrhosisEtiology of CirrhosisAlcoholic liver disease 60-70%Viral hepatitis 10%Biliary disease 5-10%Primar...
Pathogenesis of cirrhosisPathogenesis of cirrhosisHepatocellular deathRegenerationProgressive fibrosisNormal liver cons...
Pathogenesis of cirrhosisPathogenesis of cirrhosisThe induction of fibrosis occurs withactivation of hepatic stellate cell...
Pathogenesis of cirrhosisPathogenesis of cirrhosiso 3.Disruption of ECMo 4.Direct stimulation of stellate cells bytoxinsOn...
Pathogenesis of cirrhosisPathogenesis of cirrhosisNecrosis of hepatic parenchyma due to some injuryCollapse of hepatic lob...
CirrhosisCirrhosisFibrosisRegenerating Nodule
Liver Biopsy – CirrhosisLiver Biopsy – Cirrhosis
Liver Biopsy – Cirrhosis:Liver Biopsy – Cirrhosis:
Alcoholic cirrhosisAlcoholic cirrhosisEthyal alcohol is a common cause ofacute/chronic liver disease.Paterns of alcoholic ...
Pathogenesis of Alcoholic cirrhosisPathogenesis of Alcoholic cirrhosisAcetaldehyde – metabolite – hepatotoxicDiversion of ...
Alcoholic Liver DamageAlcoholic Liver Damage
Alcoholic Fatty LiverAlcoholic Fatty Liver
Alcoholic Fatty LiverAlcoholic Fatty Liver
Alcoholic Fatty LiverAlcoholic Fatty Liver
Clinical Feature of cirrhosisClinical Feature of cirrhosisSymptoms: Non specific symptoms:weakness, fatigue, anorexia Ja...
Clinical Feature of cirrhosisClinical Feature of cirrhosis
Clinical Feature of cirrhosisClinical Feature of cirrhosisSigns: Jaundice Fetor hepaticus Pedal oedema Generalized was...
Clinical Feature of cirrhosisClinical Feature of cirrhosisParotid enlargement in alcoholiccirrhosisLoss of secondary sex...
Clinical Feature of cirrhosisClinical Feature of cirrhosisAbdomen :Dilated abdominal vessels, caput medusa AscitisSple...
Palmar erythemaPalmar erythema
Clinical Feature of cirrhosisClinical Feature of cirrhosis
Ascitis in CirrhosisAscitis in Cirrhosis
Porta-systemic anastomosis:Porta-systemic anastomosis:Prominent abdominal veins.Prominent abdominal veins.
Gynaecomastia in cirrhosisGynaecomastia in cirrhosis
Splenomegaly in cirrhosisSplenomegaly in cirrhosis
Submucosal veins in the esophagus become dilated. TheseSubmucosal veins in the esophagus become dilated. Theseare known as...
Lab investigationsLab investigationsLiver function: serum albumin andprothrombin are the best indicator of liverfunctions...
Lab investigationsLab investigationsSerum electrolytes: A low sodium indicatesevere disease due to defect in the freewate...
Lab investigationsLab investigations Other test to identify the causeViral marker : HBsAg,Anti HCVAlpha-1 antitripsinS...
ImagingImagingUltrasonogram examinition:◦ Liver may show coarse ecotexture◦ Dilated portal veins◦ Splenomegaly◦ AscitisC...
Prognosis of CirrhosisPrognosis of CirrhosisPoor prognostic indicator of cirrhosis:Blood tests low Serum albumin is( <28 ...
Prognosis of CirrhosisPrognosis of CirrhosisNeuropsychiatric complications developingwith progressive liver failurePersi...
Prognosis of CirrhosisPrognosis of CirrhosisPrognosis can be assessed by usingCHILD-PUGH CLASSIFICATIONPrameterAscitis No...
Prognosis of CirrhosisPrognosis of CirrhosisScore5-6 grade A (well-compensateddisease)Score 7-9 grade B (Significant fun...
Complication of cirrhosisComplication of cirrhosis1. Ascitis2. Spontaneous bacterialperitonitis3. Heamatemesis4. Enchaphal...
THANKYOU
Cirrhosis of liver.2003 all
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  1. 1. CIRRHOSIS OF LIVERCIRRHOSIS OF LIVERDr. Mizanur Rahman Chowdhury
  2. 2. EpidemiologyEpidemiology40% cases asymptomaticIt is the 12thleading cause of death inUnited States.Approximately 30,000 to 50,000 deathsper yearAdditional 10,000 deaths due to livercancer secondary to cirrhosis
  3. 3. CirrhosisCirrhosisDefinition: It is the end stage of liverdisease characterized byBridging fibrous septa in the form ofdelicate bands or broad scar linkingportal tracts with one another and portaltracts with terminal hepatic veinParenchymal nodules containinghepatocytes encircled by fibrosisDisruption of architecture entire of liver
  4. 4. Normal LiverNormal Liver
  5. 5. Normal Liver HistologyNormal Liver HistologyCVPT
  6. 6. Histological classificationHistological classificationMicronodular Cirrhosis :Thickregular septa and regenerating smallnodules varying little in size andinvolvement of every lobule, mainlyseen in alcoholic cirrhosis.Size of the nodule is less than 1cm
  7. 7. Histological classificationHistological classificationMicronodular Cirrhosis
  8. 8. Micronodular cirrhosis:Micronodular cirrhosis:
  9. 9. Histological classificationHistological classificationMacronodular Cirrhosis :Septaand nodules of variable size andnormal lobules in larger nodules,mainly seen in post necroticcirrhosis.Size of the nodule is more than 1cm
  10. 10. Histological classificationHistological classificationMacronodular Cirrhosis
  11. 11. Histological classificationHistological classificationMacronodular Cirrhosis
  12. 12. Aetiological classificationAetiological classificationViral: Chronic Hepatitis B, Hepatitis Cinfection.AlcoholNon alcoholic fatty liverMetabolic disorder:Haemochromatosis, Wilson’sdisease,Alpha-1 antripsin deficiency.Autoimmune HepatitisPrimary biliary cirrhosis
  13. 13. Aetiological classificationAetiological classificationProlong cholestasisHepatic venous outflow obstruction:Constrictive pericarditis, Veno occlusivedisease, Budd chairi syndrome.Drugs: Methotraxate, Amioderone.Cryptogenic: Unknown origin.
  14. 14. Etiology of CirrhosisEtiology of CirrhosisAlcoholic liver disease 60-70%Viral hepatitis 10%Biliary disease 5-10%Primary hemochromatosis 5%Cryptogenic cirrhosis 10-15%Wilson’s, α1AT def rare
  15. 15. Pathogenesis of cirrhosisPathogenesis of cirrhosisHepatocellular deathRegenerationProgressive fibrosisNormal liver consists of I, III , IV Collagenin portal tracts and around central veins.A delicate reticulin network of IV collagenin the space of disse “( b/w sinusoidalendothelial cell and hepatocyte.) Incirrhosis there is deposition of type I, IIIand other components of ECM aredeposited in all portion of lobule .
  16. 16. Pathogenesis of cirrhosisPathogenesis of cirrhosisThe induction of fibrosis occurs withactivation of hepatic stellate cells,resulting in formation of increasedamounts of collagen & othercomponents of extracellular matrix.Stimuli :o1.Chr.inflammation – cytokines like TNF,Lymphotoxin, IL-1o 2.Cytokine production by injuredKupffer cells, endothelial cells,hepatocytes, bile duct epithelial cells
  17. 17. Pathogenesis of cirrhosisPathogenesis of cirrhosiso 3.Disruption of ECMo 4.Direct stimulation of stellate cells bytoxinsOn the other hand portal hypertensiondeveloped in following way
  18. 18. Pathogenesis of cirrhosisPathogenesis of cirrhosisNecrosis of hepatic parenchyma due to some injuryCollapse of hepatic lobuleFormation of diffuse fibrous septaNodular regrowth of liver cellsAltered hepatic vasculaturePortal blood flow is impairedDevelopment of portal hypertensionCirrhosis of liver
  19. 19. CirrhosisCirrhosisFibrosisRegenerating Nodule
  20. 20. Liver Biopsy – CirrhosisLiver Biopsy – Cirrhosis
  21. 21. Liver Biopsy – Cirrhosis:Liver Biopsy – Cirrhosis:
  22. 22. Alcoholic cirrhosisAlcoholic cirrhosisEthyal alcohol is a common cause ofacute/chronic liver disease.Paterns of alcoholic liver disease:1. Fatty change2. Acute Hepatitis3. Chronic hepatitis with fibrosis4. Cirrhosis, Chronic liver failureAll are reversible except cirrhosisstage
  23. 23. Pathogenesis of Alcoholic cirrhosisPathogenesis of Alcoholic cirrhosisAcetaldehyde – metabolite – hepatotoxicDiversion of metabolism – fat storageOxidation of ethanol NAD to NADH. NAD isrequired for the oxidation of fat..Increased peripheral release of fatty acidsInflammation, Portal bridging fibrosisStimulates collagen synthesis – fibrosisMicronodular cirrhosis
  24. 24. Alcoholic Liver DamageAlcoholic Liver Damage
  25. 25. Alcoholic Fatty LiverAlcoholic Fatty Liver
  26. 26. Alcoholic Fatty LiverAlcoholic Fatty Liver
  27. 27. Alcoholic Fatty LiverAlcoholic Fatty Liver
  28. 28. Clinical Feature of cirrhosisClinical Feature of cirrhosisSymptoms: Non specific symptoms:weakness, fatigue, anorexia JaundiceAbdominal distensionSwelling if legsLoss of libido in males and amenorrhoeain females.Low grade feverLess commonly symptoms of complicationsuch as epistaxis, heamatemesis,melaena, menorrhagia.
  29. 29. Clinical Feature of cirrhosisClinical Feature of cirrhosis
  30. 30. Clinical Feature of cirrhosisClinical Feature of cirrhosisSigns: Jaundice Fetor hepaticus Pedal oedema Generalized wasting Hands: Leuconychia, clubbing, Jaundice,Flapping tremor, palmar erythema, dupuytren’scontructure
  31. 31. Clinical Feature of cirrhosisClinical Feature of cirrhosisParotid enlargement in alcoholiccirrhosisLoss of secondary sexual hair, axillaryand pubicGynaecomastia in males and breastatrophy in females.Testicular atrophy in males.skin: spider naevi in the upper limbsand chest, generalized pigmentation,purpura, bruising
  32. 32. Clinical Feature of cirrhosisClinical Feature of cirrhosisAbdomen :Dilated abdominal vessels, caput medusa AscitisSplenomegalyHepatomegalyHaemorrhoid
  33. 33. Palmar erythemaPalmar erythema
  34. 34. Clinical Feature of cirrhosisClinical Feature of cirrhosis
  35. 35. Ascitis in CirrhosisAscitis in Cirrhosis
  36. 36. Porta-systemic anastomosis:Porta-systemic anastomosis:Prominent abdominal veins.Prominent abdominal veins.
  37. 37. Gynaecomastia in cirrhosisGynaecomastia in cirrhosis
  38. 38. Splenomegaly in cirrhosisSplenomegaly in cirrhosis
  39. 39. Submucosal veins in the esophagus become dilated. TheseSubmucosal veins in the esophagus become dilated. Theseare known as esophageal varices. Varices are seen here inare known as esophageal varices. Varices are seen here inthe lower esophagus as linear blue dilated veins. There isthe lower esophagus as linear blue dilated veins. There ishemorrhage around one of them. Such varices are easilyhemorrhage around one of them. Such varices are easilyeroded, leading to massive gastrointestinal hemorrhageeroded, leading to massive gastrointestinal hemorrhage
  40. 40. Lab investigationsLab investigationsLiver function: serum albumin andprothrombin are the best indicator of liverfunctions.o Albumin is less than 28 g/loProthrombin time increase according to theseverity of the diseaseoSerum bilirubin is elevatedLiver biochemistry: this can be normaldepending on the severity of the cirrhosisoALP is elevatedoALT is elevated
  41. 41. Lab investigationsLab investigationsSerum electrolytes: A low sodium indicatesevere disease due to defect in the freewater clearance or excess diuretictherapy. Serum Creatinine: An elevationconcentration of more than 130micromol/lindicate worse prognosisIn addition Alpha feto protein more than200ng/ml strongly suggest that hepatocellular carcinoma
  42. 42. Lab investigationsLab investigations Other test to identify the causeViral marker : HBsAg,Anti HCVAlpha-1 antitripsinSerum copper, CaeruloplasminSerum immunoglobulinAuto antibodyIron indices,ferritin
  43. 43. ImagingImagingUltrasonogram examinition:◦ Liver may show coarse ecotexture◦ Dilated portal veins◦ Splenomegaly◦ AscitisCT scan may show hepatosplenomegalyand dilated collaterals are seen in chronicliver diseaseUpper GI endoscopy: Oesophageal varicesmay seen LIVER BIOPSY IS CONFIRMATORY
  44. 44. Prognosis of CirrhosisPrognosis of CirrhosisPoor prognostic indicator of cirrhosis:Blood tests low Serum albumin is( <28 g/l)Low Sodium is (<125mmol/l)Prolong prothrombin time(> 6sec)Serum Creatinine is (> 130micromol/l)ClinicalPersistent jaundiceAscitisFailure of response to therapyHemorrhage from the varices,particolarly withpoor liver function
  45. 45. Prognosis of CirrhosisPrognosis of CirrhosisNeuropsychiatric complications developingwith progressive liver failurePersistent hypertensionSmall liverAetiology eg.alcoholic cirrhosis if thepatient continue to drink alcohol
  46. 46. Prognosis of CirrhosisPrognosis of CirrhosisPrognosis can be assessed by usingCHILD-PUGH CLASSIFICATIONPrameterAscitis None Mild Moderate/SevereEnchaphalopathyNone Mild MarkedBilirubin <2mg/dl 2-3mg/dl >3mg/dlAlbumin >3.5g/dl 2.8-3.5g/dl <2.8g/dlProthrombintime<4 4-6 >6
  47. 47. Prognosis of CirrhosisPrognosis of CirrhosisScore5-6 grade A (well-compensateddisease)Score 7-9 grade B (Significant functionalcompromise)Score 10-15 grade C (Decompensateddisease)
  48. 48. Complication of cirrhosisComplication of cirrhosis1. Ascitis2. Spontaneous bacterialperitonitis3. Heamatemesis4. Enchaphalopathy5. Hepatocellular carcinoma6. Hepato renal syndrome7. Increased susceptibility ofinfection
  49. 49. THANKYOU
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