detail presentation about liver cirrhosis with management and case scenarios

1. DR.AFRIN NEEHA , DNB GENERAL MEDICINE
CIRRHOSIS OF LIVER
ALCOHOL ASSOCIATED, CHRONIC HEP B /C ASSOCIATED, AIH AND
NAFLD,CARDIAC CIRRHOSIS, COMPLICATIONS-PORTAL HYPERTENSION

2. CASE 1

3. Case 1
• 55 yr /M
• C/0 fever,bloating,yellow
discoloration of eyes
• Examination:
• Tender and palpable liver
• H/0 alcohol misuse from
last 20 years
• No other comorbidities
• Skin
fi
nding?
• Diagnosis?
• Further workup?
• Treatment?

7. ALCOHOL ASSOCIATED CIRRHOSIS
• Alcohol ass. Fatty liver ,Alcohol associated hepatitis, alcohol associated cirrhosis
• Ch.alcohol use can produce
fi
brosis in absence of in
fl
ammation/necrosis
• Alcohol ass.cirrhosis: nodules<3 mm D-micronodular cirrhosis.
• Micro nodular and macro nodular cirrhosis.
• Alcohol associated cirrhosis accounts for 48% of deaths due to cirrhosis
• CT appears in both periportal and pericentral zones and eventually connects
portal triads with central veins forming regenerative nodules.
• C/F: non speci
fi
c :vague right upper quadrant abdominal pain , fever , nausea and
vomiting, diarrhea, anorexia and malaise.
• Speci
fi
c: ascites, edema , UGI hge, jaundice /encephalopathy

8. ALCOHOLIC HEPATITS
• Rapid onset of jaundice (serum bilirubin>3mg/dl), fever , malaise ,tender
hepatomegaly and clinical signs of decompensation(ascites, bacterial
infection, vatical bleeding, and hepatic encephalopathy)
• SIRS+AKI (secondary to hepatorenal syndrome)
• Lab
fi
nding:ALH ,AST:ALT>1.5(400), serum bilirubin >3
• To rule out: biliary obstruction and HCC
• ALH have underlying cirrhosis-80%

10. • Zieves syndrome?
• AST:ALT ratio =2:1
• TREATMENT:
• ABSTINENCE
• Drugs that reduce craving of alcohol:
• Acamprosate calcium and baclofen
• glucocorticoids->7 days failure to
improve bilirubin- treatment failure
• Continued for 28 days
• IV NAC + glucocorticoids:survival
bene
fi
t in alcoholic hepatitis.

16. CASE 2

17. CASE 2
• 52 Yr/M
• C/o pedal edema
• Hep C , 3 years ago, not
on DAA
• CBP- platelets:1.8L,
Hb:11mg/dl
• DM-2, HTN
• Finding?
• Investigations?
• Treatment?

18. HEP C ASSOCIATED CIRRHOSIS

19. HEP C /B ASSOCIATED
• HCV exposed- 80 % developed ch.hep C
• Non cytopathic virus, immune mediated liver damage.
• micro and macro nodular cirrhosis on liver Bx.(similar
fi
ndings in hep B)
• Dx: HCV RNA, analysis of HCV genotype or hep b serologies to include
HbsAg, anti hbs, HbeAg, anti Hbe aqnd quantitative HBV DNA levels
• Treatment:
• Several clinical trials and case series: decompensated liver disease can
become compensated with the use of antiviral therapy in hep b(entecavir and
tenofovir)- reduced risk of viral resistance
• Hep c: DAA protocol:- >95% cure (8-12 weeks)n well tolerated.

20. CASE 3

21. CASE 3
• 67 yr/M
• C/o: SOB , pedal edema
since last 8 months
• Non alcoholic
• H/o snoring, weight gain .
• UGIE:portal gastropathy
• Finding?
• Investigations?
• Treatment?

22. PORTAL GASTROPATHY

23. NAFLD

25. NAFL- CIRRHOSIS
• NAFLD cirrhosis associated with 1-25 risk of developing primary liver
cancer(HCC& intrahepatic cholangiocarcinoma)
• NAFLD associated with insulin resistance , overweight/obesity and metabolic
syndrome.
• Advanced hepatic
fi
brosis is primary predictor of liver related morbidity and
mortality
• NAFLD related cirrhosis associated annual incidence of primary liver
cancer:1-2% per year
• Increased heritability of NAFLD: TMS6SF2,MBOAT7,PNPLA3(Intracellukar
tra
ffi
cking of lipids)
• Premalignant?

28. DX and RX
• Serum aminotransferases do not re
fl
ect NASH vs NAFLD
• Non invasive quanti
fi
cation of liver fat: MRI-PDFF:proton density fat fraction
• NAFLD
fi
brosis score and FIB4 (two most commonly employed non invasive tests to assess severity of
hepatic
fi
brosis
• Liver sti
ff
ness: MRE(magnetic resonance elastography ) and Fibroscan
• NASH :2*3 increased risk of metabolic syndrome
• NAFLD, independently associated with endothelial dysfunction, increased carotid intimal thickness and
number of plaques in carotid and coronary arteries.
• Three components:
• Speci
fi
c therapy
• Treatment of associated comorbidities
• Treatment of complications

30. CASE 4

31. CASE 4
• 48yr/M
• Dermatology clinic with c/o
intense pruritis
• Previous reports:as shown
• H/o abdominal pain , bloody
diarrhea, weight loss -7
years
• Examination: icteric, skin
fi
ndings as shown
• Skin
fi
nding?
• Primary diagnosis?
• Further workup?

32. PRIMARY SCLEROSING
CHOLANGITIS

36. ONION SKIN PEELING-PSC
FLORID DUCT LESION-PBS

37. PORTAL HYPERTENSION

38. • Def: elevation of hepatic venous pressure gradient >5 mm hg
• 5-10 mm hg:asymptomatic
• Pathology:
• 1)increased intrahepatic resistance
• 2)increased splanchnic blood
fl
ow due to vasodilatation
• Variceal hemorrhage:life threatening complication
•

43. ESOPHAGEAL
VARICES
ON UGIE

46. THANK YOU