Liver cirrhosis, its causes, how to diagnose, stage an dmanage the disease.

1. CIRRHOSIS
AND ITS
COMPLICATIONS
Ujala Abdul Rashid
House Officer, MU-2

2. Presentation
Outline
What is
Cirrhosis
Causes of
Cirrhosis
Reaching a
Diagnosis
Staging the
Disease
Complications
Management

3. What is
Cirrhosis
• Defined histopathologically
• Development of fibrosis leading
to architectural distortion with
the formation of regenerative
nodules.
• This results in:
Decrease in cell mass, and
thus function
An alteration of blood flow

4. Causes of Cirrhosis
90%
40%
40-45%
40-45%
Alcoholic Cirrhosis
(Western Statistics)
Cirrhosis due to
Chronic hepatitis B or
C infection
Cirrhosis due to
Autoimmune hepatitis
and Non Alcoholic
Steatohepatitis
Others:
Biliary Cirrhosis
Cardiac Cirrhosis
Cryptogenic Cirrhosis
Cirrhosis due to
metabolic disorders

5. Reaching a
Diagnosis
Staging
History
Investigations
Physical
Examinati
on

6. History

7. Physical
Examination

8. Investigations
CBC:
Anemia.
Thrombocytopenia
LFTs:
Serum total bilirubin elevated with advanced disease
ALT, AST are elevated, A/G ratio is usually 2:1 ratio in severe heapatocellular damage
Elevated GGT and ALP (in cholestasis)
Albumin levels are decreased
Prothrombin times are prolonged
S/E:
Serum sodium levels are decreased if patient has ascites largely due to ingestion of excess free water.
Viral studies:
Auto immune markers:
Anti ANA, anti ASMA antibodies (AIH)
Anti mitochondrial antibodies (PBC)
P-ANCA (PSC)
Imaging Studies
Endoscopy
Iron studies and copper studies
Liver Biopsy: (most specific)
Micronodular cirrhosis: Alcoholic cirrhosis
Macronodular cirrhosis
Mixed pattern: Hepatitis C
Non invasive markers

9. Staging the
Disease
• Compensated cirrhosis
• Decompensated cirrhosis
•Portal hypertension leading to
ascities and bleeding from varices
•Portosystemic encephalopathy

10. Child Turcotte Pugh Classification:

11. Complications
• Complications due to
architectural damage
• Complications due to hepatic
dysfunction

12. Portal hypertension
• Gastroesophageal varices
• Portal hypertensive
gastropathy
• Splenomegaly, hypersplenism
• Ascities
• Spontaneous bacterial
peritonitis
Complications due
to hepatic
dysfunction:
• Hepatic encephalopathy
• Hepatorenal syndrome
• Hepatopulmonary
syndrome
• Malnutrition
• Coagulopathy
• Bone disease
• Hematologic abnormalities
Portopulmonary
hypertension
Complications due to
architectural damage:

13. Ascities:
 Clinical features:
Abdominal distension
 On Examination:
• Increase in abdominal girth
• Umbilicus everted/protruding
• Fluid thrill/ Shifting dullness
 Chemical Analysis:
• Clear, straw colored or light green
• Transudative and contains relatively less cells
• SAAG> 1.1 g/dl
• Low amylase and triglycerides
• Glucose: normal
• Abcence of malignant cells
 Management:
• Sodium restriction (100 mmol/24 hr) and water
restriction (1-1.5 L/24 hrs)
• Diuretics (spironolactone 100-400 mg/day or amiloride
5-10 mg)
• Paracentesis
• TIPSS
 Complications:
• Renal failure
• Hepatorenal syndrome
• Spontaneous bacterial peritonitis

14. Hepatic Encephalopathy:
 Clinical features:
• Changes of intellect, personality, emotions and consciousness with or without neurological signs
 On Examination:
• Flapping tremors
• Constructional apraxia
• Hyperreflexia with up going planters
• Fetor hepaticus
 Precipitating factors:
• Drugs
• Dehydration
• Infection
• Hypokalemia
• Constipation
• Portosystemic shunting
 Management:
• Treat and remove the precipitating cause
• Lactulose (15-30 ml TDS)
• Rifaximin (400 mg TDS)
• Liver transplant

15. Management:

16. Cause Management
Alcoholic cirrhosis Abstinence, glucocorticoids, pentoxyfylline
Cirrhosis due to viral hepatitis Anti viral agents (adefovir, lamivudine, interferon,
ribavirin)
Cirrhosis due to AIH and non alcoholic
steatohepatitis
Glucorticoids, immunosuppressive therapy, liver
transplant
Biliary cholangitis Ursodeoxycholic acid, obeticholic acid,
immunosuppressive agents
For pruritus: Antihistamines, naltrexone, rifampin or
cholestyramine, plasmaphoresis
For osteopenia: bisphosphonates
Endoscopic dilatation of strictures
Liver transplant
Cardiac cirrhosis Treatment of cardiac failure
Metabolic causes Regular therapeutic phlebotomy
Copper-chelating medications
Liver transplant
Cause Directed Management:

17. Thank You