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  • • Develops in 15% of alcoholics

    • Alcoholism most common cause

    • Other causes include:

    • -Idiopathic

      -Viral hepatitis

      -Hemochromatosis

      -Wilson disease

      -Primary biliary cirrhosis

      -Primary sclerosing cholangitis

      -Budd-Chiari syndrome

      -Tricuspid regurgitation or stenosis

    • Chronic allograft rejection in patients with liver transplant

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Epidemiology

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  • • Increasing incidence in United States

    • Males affected more than females

    • Third leading cause of death among men during the fifth decade

    • 10-30% of patients with chronic hepatitis B and C have cirrhosis

    • 30% mortality rate at 1 year after diagnosis

    • Variceal bleeding, 50%

    • Variceal bleed mortality, 50%

    • Viral hepatitis most common worldwide

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Symptoms and Signs

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  • • Jaundice

    • Ascites

    • Bleeding varices

    • Edema

    • Spider angiomas

    • Dark urine

    • Light-colored stools

    • Encephalopathy

    • Splenomegaly

    • Hepatomegaly (early)

    • Palmar erythema

    • Gynecomastia

    • Dupuytren contractures

    • Dyspnea

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Laboratory Findings

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  • • Hyperbilirubinemia

    • Hypoalbuminemia

    • Prolonged prothrombin time

    • Elevated creatinine

    • Occasional elevated transaminases

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Imaging Findings

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  • • Ascites on CT or US

    • Hepatic fibrosis and nodularity on CT or US

    • Hepatofugal portal vein flow on duplex or thrombosis

    • Splenomegaly on CT

    • Dilated venous collaterals on CT

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  • • Etiology (alcohol, viral, hemochromatosis, Wilson disease)

    • Liver biopsy

    • Hepatoma

    • GI bleeding

    • Infection

    • Model for End-Stage Liver Disease (MELD) criteria:

    • -Bilirubin

      -International normalized ratio (INR)

      -Creatinine (Cr)

      -Etiology

    • MELD change over time

    • Child-Pugh classification of functional status in liver diseases.

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Table Graphic Jump Location
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Class: ABC
Risk: LowModerateHigh
AscitesAbsentSlight to moderateTense
EncephalopathyNoneGrades I-IIGrades III-IV
Serum albumin (g/dL)≥ 3.53.0-3.5< 3.0
Serum bilirubin (g/dL)< 2.02.0-3.0> 3.0
Prothrombin time (seconds above control)< 4.04.0-6.0> 6.0
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Rule Out

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  • • GI bleeding, hepatoma, and infection all could cause cirrhotic decompensation or first presentation of cirrhosis

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  • • History and physical exam

    • Liver function tests

    • Renal function tests

    • Hepatitis serologies

    • Liver biopsy (for unclear cases)

    • Esophagoscopy with or without sclerotherapy for varices

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When to Admit

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  • • Decompensated cirrhosis

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Surgery

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  • • Liver transplantation

    • Resection for selected hepatomas

    • Radiofrequency ablation for selected hepatomas

    • Transjugular intrahepatic portasystemic shunt (TIPS) vs surgical shunt for portal hypertension

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Indications

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  • • Relative MELD score for liver transplantaion

    • Residual liver function for resection vs radiofrequency ablation for hepatoma

    • Bleeding varices for shunt

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Contraindications

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  • • To liver transplantation

    • -Continued alcoholism

      -Medical comorbidities

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Medications

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  • • Aldactone

    • Lactulose

    • β-Blockers

    • Low protein, low salt diet

    • Change or increase immunosuppression for chronic allograft rejection following transplantation

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Treatment Monitoring

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