Cirrhosis

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Cirrhosis

  1. 1. CHRONIC HEPATITIS <ul><li>Hepatic inflammation and necrosis continue for at least 6 months </li></ul><ul><li>Classification: cause, grade, stage </li></ul>
  2. 2. By Cause <ul><li>Hepatitis B </li></ul><ul><li>Hepatitis B and D </li></ul><ul><li>Hepatitis C </li></ul><ul><li>Autoimmune Hepatitis </li></ul><ul><li>Drug-associated chronic hepatitis </li></ul><ul><li>Cryptogenic hepatitis </li></ul>
  3. 3. By Grade <ul><li>Piecemeal necrosis – periportal necrosis and disruption of the limiting plate </li></ul><ul><li>Bridging necrosis –confluent necrosis that forms bridges between portal tracts and central vein </li></ul><ul><li>Degree of hepatocyte degeneration </li></ul><ul><li>Portal inflammation </li></ul><ul><li>Scoring Indices: HAI, METAVIR </li></ul>
  4. 4. Table 300-2
  5. 5. Table 300-2
  6. 6. Chronic Viral Hepatitis <ul><li>Hepatitis A and E – no chronic forms </li></ul><ul><li>Hepatitis B </li></ul><ul><li>Hepatitis C </li></ul><ul><li>Hepatitis B with superimposed Hepatitis D </li></ul>
  7. 7. Chronic Hepatitis B <ul><li>Likelihood of chronicity varies with age </li></ul><ul><li>Infection at birth: clinically silent but 90% chance of chronic infection </li></ul><ul><li>In adults: acute infection associated with clinical symptoms but risk of chronicity is 1% </li></ul><ul><li>Liver injury: absent (carriers), mild , moderate, severe </li></ul>
  8. 8. Survival Rates <ul><li>5 Years </li></ul><ul><li>Mild 97% </li></ul><ul><li>Moderate-severe 86% </li></ul><ul><li>Cirrhosis 55% </li></ul><ul><li>15 Years </li></ul><ul><li>Mild 77% </li></ul><ul><li>Moderate-severe 66% </li></ul><ul><li>Cirrhosis 40% </li></ul>
  9. 9. CHB: Clinical features <ul><li>Broad: asymptomatic  debilitating  end stage hepatic failure </li></ul><ul><li>Fatigue, anorexia </li></ul><ul><li>Jaundice (persistent, intermittent) </li></ul><ul><li>Ascites, edema </li></ul><ul><li>Bleeding varices, encephalopathy, coagulopathy, hypersplenism </li></ul>
  10. 10. CHB: Laboratory Features <ul><li>Elevated bilirubin levels </li></ul><ul><li>Elevated ALT/AST </li></ul><ul><li>Alk Phos – marginally elevated </li></ul><ul><li>Hypoalbuminemia </li></ul><ul><li>Prolongation of Prothrombin time </li></ul>
  11. 11. Lab: hepatitis B markers <ul><li>HBsAg </li></ul><ul><li>Anti HBs </li></ul><ul><li>HBeAg: viral replication, infectivity, liver injury </li></ul><ul><li>AntiHBe </li></ul><ul><li>HBVDNA viral load </li></ul>
  12. 12. Clinical Forms of Hep B <ul><li>HBeAg + CHB: ALT & HBVDNA elevated </li></ul><ul><li>HBeAg – CHB: ALT & HBVDNA elevated (pre-core mutants </li></ul><ul><li>Hepatitis B carrier: ALT normal; HBVDNA low or undetectable </li></ul>
  13. 13. Cirrhosis <ul><li>Past: irreversible </li></ul><ul><li>Present: reversible, Chronic Hep C, hemochromatosis </li></ul><ul><li>Pathology: hepatic fibrosis  architectural distortion with formatiion of regenarative nodules; decrease in hepatocellular mass/function; alteration of blood flow </li></ul><ul><li>Survival rate: < 50% in 5 years </li></ul>
  14. 14. Clinical Features <ul><li>Portal HPN: ascites, variceal bleeding </li></ul><ul><li>Loss of hepatocellular: decrease in hepatocellular mass/function, alteration of blood flow </li></ul><ul><li>Survival rate: <50 % in 5 years </li></ul>
  15. 15. Alcoholic Cirrhosis <ul><li>Types: CLD, Fatty Liver, Alcoholic hepatitis, alcoholic cirrhosis </li></ul><ul><li>Micronodular type - <3mm </li></ul><ul><li>Clinical Features: </li></ul>
  16. 16. Clinical features <ul><li>RUQ discomfort </li></ul><ul><li>Fever </li></ul><ul><li>Nausea & vomiting </li></ul><ul><li>Anorexia </li></ul><ul><li>Malaise </li></ul><ul><li>Ascites </li></ul><ul><li>Edema </li></ul><ul><li>GI bleeding </li></ul><ul><li>Hepatomegaly </li></ul><ul><li>Splenomegaly </li></ul><ul><li>Jaundice </li></ul><ul><li>Palmar erythema </li></ul><ul><li>Spider nevi </li></ul><ul><li>Parotid enlargement </li></ul><ul><li>Gynecomastia </li></ul><ul><li>Testicular atrophy </li></ul>
  17. 17. Laboratory Investigations <ul><li>Anemia </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>Elevated bilirubin </li></ul><ul><li>Prolonged prothrombin time </li></ul><ul><li>Elevated AST, ALT </li></ul>
  18. 18. Therapy <ul><li>Abstinence </li></ul><ul><li>Supportive treatment of complications </li></ul><ul><li>Steroids </li></ul><ul><li>TNF antagonist, Pentoxifylline </li></ul>
  19. 19. Post Necrotic Cirrhosis <ul><li>Hep B+  CHB 5%  Cirrhosis 25% </li></ul><ul><li>Hep C+  CHC 80%  Cirrhosis 20- 30% </li></ul><ul><li>Clinical Features </li></ul><ul><li>Labs: Hep B markers, HBVDNA </li></ul><ul><li>HCVRNA, genotype </li></ul><ul><li>Rx:Interferons, Nucleoside analogues </li></ul><ul><li> Interferons, Ribavirin </li></ul>
  20. 20. Clinical features <ul><li>RUQ discomfort </li></ul><ul><li>Fever </li></ul><ul><li>Nausea & vomiting </li></ul><ul><li>Anorexia </li></ul><ul><li>Malaise </li></ul><ul><li>Ascites </li></ul><ul><li>Edema </li></ul><ul><li>GI bleeding </li></ul><ul><li>Hepatomegaly </li></ul><ul><li>Splenomegaly </li></ul><ul><li>Jaundice </li></ul><ul><li>Palmar erythema </li></ul><ul><li>Spider nevi </li></ul><ul><li>Parotid enlargement </li></ul><ul><li>Gynecomastia </li></ul><ul><li>Testicular atrophy </li></ul>

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