Cirrhosis

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • Jaundice

  • Ascites

  • Bleeding varices

  • Edema

  • Spider angiomas

  • Dark urine

  • Light-colored stools

  • Encephalopathy

  • Splenomegaly

  • Hepatomegaly (early)

  • Palmar erythema

  • Gynecomastia

  • Dupuytren contractures

  • Dyspnea

Laboratory Findings

• • Hyperbilirubinemia

  • Hypoalbuminemia

  • Prolonged prothrombin time

  • Elevated creatinine

  • Occasional elevated transaminases

Imaging Findings

• • 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

• • 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.

Rule Out

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

• • History and physical exam

  • Liver function tests

  • Renal function tests

  • Hepatitis serologies

  • Liver biopsy (for unclear cases)

  • Esophagoscopy with or without sclerotherapy for varices

When to Admit

• • Decompensated cirrhosis

Surgery

• • Liver transplantation

  • Resection for selected hepatomas

  • Radiofrequency ablation for selected hepatomas

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

Indications

• • Relative MELD score for liver transplantaion

  • Residual liver function for resection vs radiofrequency ablation for hepatoma

  • Bleeding varices for shunt

Contraindications

• • To liver transplantation

  • -Continued alcoholism

    -Medical comorbidities

Medications

• • Aldactone

  • Lactulose

  • β-Blockers

  • Low protein, low salt diet

  • Change ...