This document discusses gastrointestinal dysfunction that is common in patients with liver cirrhosis. It can impact quality of life, nutritional status, and contribute to the development of cirrhosis complications. Specific issues covered include malnutrition prevalence of up to 80%, common GI symptoms in up to 80% of patients such as abdominal bloating and pain, impaired gastric functions like accommodation and emptying, increased intestinal permeability, and endoscopic findings including peptic ulcers in 24.1% of patients, gastroesophageal varices in over 50% of those with portal hypertension, and portal hypertensive gastropathy in around 80% of cirrhosis patients. The pathogenesis and management of these GI complications are also reviewed.

1. Gastrointestinal Dysfunction
in Liver Cirrhosis
Head of Gastroenterology , Hepatology Department
Qabbary Specialized Hospital

2. Features of gut dysfunction are common in
patients with cirrhosis and may have an impact on
 Quality of life
 nutritional status
 contribute the development of cirrhosis complication

3. Gastrointestinal Dysfunctionin Liver Cirrhosis
 Malnutrtion in patients with cirrhosis
 GI symptoms in patients with cirrhosis
 Gastric sensomotor functions
Gastric accommodation
Gastric sensitivity to distension
Gastric emptying
Small bowel motility
Intestinal permeability
 The structural changes of the GI tract in liver cirrhosis( Endoscopic
changes)

5. Malnutrition
 Malnutrition is common in cirrhosis with a reported prevalence as high
as 80%
 severe muscle wasting (sarcopenia) has been shown to be present in
30%-41% of patients with cirrhosis and to be independently related to
mortality in general as well as in patients with hepatocellular cancer

6. pathogenesis

7. 
The pathogenesis of malnutrition in liver cirrhosis

8. The pathogenesis of malnutrition in liver cirrhosis

10. GI symptoms in patients with
cirrhosis

11.  up to 80% of patients with cirrhosis have been reported to
have one or more relevant GI symptoms
 The most common GI symptoms reported include
abdominal bloating in 49.5% of patients, abdominal pain in
24%, belching in 18.7%, diarrhea in 13.3%, and constipation
in 8%
 GI symptom severity appears to be related to
 liver disease severity
 lactulose use
 the presence of ascites
 psychological distress
 low serum testosterone levels

13. Gastric sensomotor functions
Gastric accommodation
In the fasting state, the proximal stomach smooth muscle
maintains a tonic contractile activity. During and after food ingestion, a relaxation of the
proximal stomach occurs, providing the meal with a reservoir and enabling
a volume increase without a rise in pressure (gastric accommodation reflex)
Impaired gastric accommodation has been associated with upper GI symptoms, such as
early satiety, bloating, and epigastric pain,
although it appears reasonable that meal-induced accommodation is impaired in the
presence of tense ascites, to date, it remains unclear how it is affected in
patients with cirrhosis of different etiologies without signifcant ascites

14. Gastric sensitivity to distension
sensory thresholds were related to gastrointestinal symptom severity and liver disease severity,
expressed as the Child-Pugh and MELD scores (lower threshold
with increasing symptom and liver disease severity)
Gastric emptying
Most studies in cirrhosis have found gastric emptying
to be delayed
Small bowel motility
In a recent study on gut transit in cirrhosis, about 35% of patients showed delayed small bowel
residence times which was related to increased diarrhea and
abdominal pain.
Intestinal permeability:
Recent evidence suggests the presence of gut barrier dysfunction in patients with
cirrhosis, especially those with severe liver disease.
Intestinal hyperpermeability has also been shown to be more common in patients
with a history of spontaneous bacterial peritonitis.
Increased permeability upon hospital admission has also been reported to be a predictor
of bacterial infections in cirrhosis

16. COMMON ENDOSCOPIC DIAGNOSES
AND MANAGEMENT IN PATIENTS WITH
LIVER DISEASE
Peptic ulcer disease
 The correlation between peptic ulcer disease and cirrhosis is well
described.
 Both duodenal and gastric ulcers are more common in cirrhosis
 the reported prevalence is 24.1%.
 It is recognized that the prevalence of gastric ulceration increases with the
severity of liver disease and is related to changes in the hepatic venous
pressure
gradient

18. Portal hypertension
 The structural effects of liver cirrhosis on the GI tract
have been considered to be mainly associated with portal
hypertension.
Gastroesophageal varices are present in > 50% of
patients with portal hypertension and are more likely as
liver disease progresses. Ectopic varices are located in
sites other than the gastroesophageal region and are more
common than previously thought: duodenal or colonic
varices are seen at angiography or colonoscopy in up to
40% of patients with intrahepatic portal hypertension

19. Esophageal varices
It is recommended that all patients undergo endoscopy
to assess the presence and the size of varices at the
time of the diagnosis of cirrhosis.
Thereafter, guidelines for
the interval of endoscopic screening vary.

21. Gastric and ectopic varices

24. Nonvariceal manifestations of portal hypertension
Portal hypertensive gastropathy (PHG),
with its typical“snake skin” appearance, is present in approximately
80% of patients with cirrhosis. PHG accounts for
8% of nonvariceal bleeds in patients with liver disease,
although this condition more commonly presents with
anemia. Patients with cirrhosis and severe PHGrelated bleeding may respond to β-blockade. Endoscopic
measures such as argon plasma coagulation (APC) therapy can reduce bleeding, thus controlling anemia.

25. portal hypertensive enteropathy
(PHE), determined by capsule endoscopy, is as high as
63% in patients with end-stage liver disease who also have
esophageal or gastric varices. Portal hypertensive duodenopathy is present in around half
of patients with cirrhosis, and it is more common in patients with severe PHG

26. Gastric antral vascular ectasia