cirrhosis

see also:

• ethanol (alcohol and alcohol withdrawal)
• steatohepatitis (fatty liver)
• gastroenterology
• prescribing drugs in patients with liver impairment
• hepatitis
• assessment of hepatic function
• hepatic encephalopathy
• hepatocellular carcinoma

• a generic term for an end stage of chronic liver disease characterised by destruction of hepatocytes & loss of normal hepatic architecture, with replacement by fibrotic tissue & regenerative nodules

• a diffuse process with involvement of the entire lobule
• most often related to chronic alcohol ingestion:
  • 10-20% of chronic alcoholics develop this type of cirrhosis
  • dependent on:
    • amount & duration of alcohol ingestion
    • heredity
    • underlying nutritional status
  • *in patients with HBV, each daily consumption of 12 g of alcohol increased the risk of cirrhosis by 6.2% and the risk of HCC by 11.5% ¹⁾

• usually non-homogeneous, characterised by regions of fibrosis & hepatocyte loss alternating with normal areas
• most often a consequence of chronic hepatitis of divergent aetiologies:
  • infectious:
    • viral:
      • 50% of pts with hep C develop cirrhosis - most within 5-10yrs
      • 10% of pts with hep B alone (10% of whom will develop hepatoma):
      • 5% pts with coinfection with hep D
      • 80% pts with superinfection with hep D
    • bacterial
    • fungal
  • drug induced
  • metabolic
  • aggressive forms of mastocytosis can cause rapid onset of cirrhosis

• much less common category
• a consequence of chronic extrahepatic biliary obstruction or as a primary disorder of autoimmune-mediated intrahepatic duct inflammation & scarring
• see primary sclerosing cholangitis / primary biliary cirrhosis

• chronic fatigue
• poor appetite
• many can be asymptomatic (except for biliary cirrhosis) until they develop some dramatic complication:
  • upper GI bleeding
  • ascites
  • hepatic encephalopathy
• cirrhosis is the main cause of hepatocellular carcinoma
• pts with biliary cirrhosis generally complain of pruritus or develop obvious jaundice before end stage cirrhosis or complications begin
• physical findings which may be present:
  • muscle wasting
  • thinning of skin with patchy ecchymosis
  • spider angiomata
  • palmar erythema
  • Dupuytren's contracture
  • gynaecomastia
  • testicular atrophy
  • jaundice - usually absent in mild or early cases
  • liver may not be palpable if it is extensively scarred, but a large regenerative nodule, tumor or fatty infiltration can result in hepatomegaly
  • advanced disease:
    • ascites
    • portal hypertension and oesophageal varices
    • caput medusae
• laboratory findings:
  • ALT is rarely more than minimally elevated, 90% have normal levels
  • bilirubin may be increased but usually not until advanced stages
  • sharp elevation of AP out of proportion to other liver enzymes suggests primary sclerosing cholangitis / primary biliary cirrhosis
  • coagulation studies commonly abnormal
  • hypoalbuminaemia due to impaired hepatic synthesis
  • mild-mod. anaemia & thrombocytopenia are often present in Laënnec's
  • elevated urea or CRN should suggest dehydration or hepatorenal syndrome