LIVER CIRRHOSIS - amu.ac.in · Reversible causes of liver fibrosis include 1. Chronic hepatitis C...
Transcript of LIVER CIRRHOSIS - amu.ac.in · Reversible causes of liver fibrosis include 1. Chronic hepatitis C...
LIVER CIRRHOSISHAIDER HUSAINI
ASSISTANT PROFESSOR
GENERAL MEDICINE
DEFINITION
▪ Diffuse hepatic fibrosis with replacement of the normal liver architecture by regenerative nodules
HEPATIC FIBROSIS
REGENERATIVE
NODULESLIVER
CIRRHOSIS
▪ Reversible causes of liver fibrosis include
1. Chronic hepatitis C
2. Hemochromatosis
3. Alcoholic Liver Disease
▪ The rate of progression of liver cirrhosis may be quite variable ranging from
➢ Decades Chronic hepatitis C
➢ Weeks Complete biliary obstruction
▪ The liver cell most commonly implicated in liver fibrosis is the hepatic stellate cell or Ito cell
▪ Activation of stellate cells occurs by the kininase activation pathways mediated through platelet derived growth factor (PDGF), TGF beta and integrin signalling pathways
▪ On activation stellate cell transforms to myofibroblasts which generates various types of matrix like fibronectin
▪ Matrix further produces collagen 1 and deposits it in place of liver parenchyma
CAUSES TYPES
VIRAL HEPATITIS HBV, HCV, HDV
AUTOIMMUNE AIH, PBC, PSC
TOXIC ALCOHOL, ARSENIC
BILIARY ATRESIA, STONE, TUMOR
VASCULAR BUDD CHIARI SYNDROME, CARDIAC
FIBROSIS
GENETIC CYSTIC FIBROSIS, LYSOSOMAL ACID LIPASE
DEFICIENCY
IATROGENIC BILIARY INJURY, METHOTREXATE
METABOLIC α1-TRYPSIN DEFICIENCY,
HEMOCHROMATOSIS,WILSON’S DS
▪ Diminished body hair
▪ Parotid enlargement
▪ Parotid enlargement
▪ Spider nevi (>3)
▪ Gynecomastia
▪ Palmar erythema
▪ Clubbing
▪ Dupuytren’s contracture
▪ Ascites/Caput medusae
▪ Testicular atrophy
• MC CAUSE OF DEATH IS CARDIOVASCULAR DS FOLLOWED BY STROKE, MALIGNANCY & RENAL DS
COMPENSATED CIRRHOSIS
• ASCITES
• VARICEAL HGE
• JAUNDICE
• ENCEPHALOPATHY
• HCC
DECOMPENSATED CIRRHOSIS
COMPENSATED CIRRHOSIS
STAGE 1=CIRRHOSIS
STAGE 2=CIRRHOSIS
+VARICES
DECOMPENSATED CIRRHOSIS
STAGE 3= CIRRHOSIS+ASCIT
ES/VARICES
STAGE 4=CIRRHOSIS+VARICEAL HGE/ASCITES
1. Portal hypertension
2. Hepatorenal syndrome type 1 & 2
3. Hepatic encephalopathy
4. Hepatopulmonary syndrome
5. Portopulmonary syndrome
6. Malnutrition
7. Coagulopathy like factor deficiency, fibrinolysis
8. Osteopenia, Osteoporosis, Osteomalacia
9. Hematologic like anemia, thrombocytopenia, hemolysis
▪ In USA, cirrhosis is the 3rd leading cause of death in the 45-64yr age group
▪ The median survival in patients with compensated cirrhosis is 9-12 yrs as compared to 2 yrs in those with decompensatedcirrhosis
▪ Prognosis depends upon clinical staging of cirrhosis as well as presence of comorbidities
▪ Generic scores to determine mortality risk in liver cirrhosis include
1. Child Turcotte Pugh Score (CTP Score)
2. Model for End stage Liver Disease (MELD) score
3. Hepatic Venous Pressure Gradient (HVPG)
4. vWF factor levels
▪ The annual rate of progression from compensated state to decompensated disease depends upon the etiology of cirrhosis
ANNUAL DECOMPENSATION RATE
HCV CIRRHOSIS
4%
HBV CIRRHOSIS
10%
ALCOHOLIC CIRRHOSIS
6-10%
▪ CBC = Anemia, thrombocytopenia
▪ LFT = deranged
▪ TSP A:G = hypoalbuminemia
▪ PT INR = increased
▪ USG abdomen = enlarged left hepatic lobe/small nodular liver/coarse liver echotexture, splenomegaly, intra abdominal collaterals, ascites
▪ Liver biopsy (GOLD STANDARD)
▪ Non invasive tests for liver fibrosis
1. Fibroscan/Transient elastography
2. Magnetic Resonance Elastography (MRE)
3. Acoustic Radiation Force Impulse Elastography (ARFI)
4. AST/Platelet ratio Index (APRI)
5. Fibrotest
6. Serum hyaluronan
▪ Frequent high calorie small meals
▪ Treat underlying cause of cirrhosis like abstinence from alcohol, anti virals for HBV & HCV, weight loss to prevent progression to decompensated liver ds
▪ Screening for esophageal varices by UGI endoscopy
▪ Surveillance for HCC with ultrasound every 6 mnths
▪ Immunization against HAV, HBV, pneumococcal pneumonia & influenza
▪ Liver transplantation
PORTAL HYPERTENSIONHAIDER HUSAINI
ASSISTANT PROFESSOR
GENERAL MEDICINE
▪ Elevation of Hepatic Venous Portal Gradient (HVPG) to > 5mmHg
CIRRHOSIS
SCHISTOSOMIASIS
NCPF
PORTAL VEIN THROMBOSIS
CARDIAC CIRRHOSIS
COMMONSARCOIDOSIS
NODULAR REGENERATIVE HYPERPLASIA
MALIGNANCY
SPLANCHNIC ARTERIVENOUS FISTULA
OSLER WEBER RENDU DS
UNCOMMON
PRE HEPATIC HEPATIC POST HEPATIC
PORTAL VEIN THROMBOSIS PRESINUSOIDAL
Schistosomiasis
Non Cirrhotic Portal Fibrosis
Congenital hepatic fibrosis
BUDD CHIARI SYNDROME
SPLENIC VEIN THROMBOSIS SINUSOIDAL
Cirrhosis
Alcoholic hepatitis
Cryptogenic cirrhosis
CARDIAC CAUSES like
Restrictive cardiomyopathy
Constrictive cardiomyopathy
Severe CHF
Severe TR
MASSIVE SPLENOMEGALY POST SINUSOIDAL
Venoocclusive ds
INFERIOR VENA CAVAL WEBS
▪ Hematemesis, malena from bleeding gastroesophageal varices
▪ Ascites
▪ Splenomegaly
▪ Hypersplenism
▪ CBC shows thrombocytopenia
▪ USG abdomen shows
oSplenomegaly
oAscites
oPortosystemic collaterals
oHepatofugal blood flow in portal vein
oPortal vein diameter > 13mm
▪ UGI endoscopy
1. PRIMARY PROPHYLAXIS
▪ Means treating those pts who have a high chance of UGI bleed
▪ Non selective beta blockers like propranolol, nadolol, carvedilol
▪ Endoscopic Variceal Ligation (EVL)
▪ Endoscopic Sclerotherapy
2. SECONDARY PROPHYLAXIS
▪ Prevention of rebleeding in a pt who has already bled
▪ Control of acute bleeding by
o Crystalloids
o Continuous iv infusion of Octeotride, Somatostatin, Vasopressin
o Balloon tamponade by Sengstaken Blakemore/Minnesota tube
▪ Transjugular Intrahepatic Portosystemic Shunt (TIPS)
▪ Portosystemic Shunt Surgery