Cirrhosis

• Irreversible liver damage
• Histologically there is loss or normal hepatic architecture with fibrosis and nodular regeneration

Causes

• Alcohol
• HBV or HCV infection
• Autoimmune disorders – Primary biliary cirrhosis, primary sclerosising cholangitis, autoimmune hepatitis
• Genetic disorders – ?1-antitrypsin deficiency, haemachromatosis, Wilson’s disease
• Budd-Chiari syndrome
• Drugs – amiodarone, methydopa, methotrexate

Signs

• See liver failure

Complications

• Hepatic failure
  • Coagulopathy
  • Encephalopathy
  • Hypoalbuminaemia
  • Sepsis
  • Spontaneous bacterial peritonitis
  • Hypoglycaemia
• Portal hypertension
  • Ascites
  • Splenomegaly
  • Portosystemic shunting

Tests

• Blood
  • LFTs – bilirubin, AST, ALT, alk phos, ?-GT
  • Reduced albumin, increased PT/INR
  • Reduced WCC and platelets indicates hypersplenism
• Finding the cause;
  • Ferritin
  • Iron/total iron binding capacity
  • Hepatitis serology
  • Immunoglobulins (IgM)
  • Autoantibodies (ANA, AMA, SMA)
  • ?-fetoprotein
  • Caeruloplasmin in patients <40
  • ?1-antitrypsin

Management

• Good nutrition – low salt diet, alcohol abstinence
• Avoid NSAIDs, opiates and sedatives
• Cholestyramine for puritis
• Consider USS and ?-fetoprotein to screen for HCC every 6mth
• Specifically;
  • Interferron- ?  improves LFTs and may delay onset of HCC in HCV cirrhosis
  • High dose ursodeoxycholic acid in PBC (normalises LFTs but doenst affect progression)
  • Penecillamine in Wilson’s disease
  • Ascites – fluid and salt restrict. Give spironolactone and if this doesn’t work add frusemide
  • SBP – common organisms are E.coli, Klebsiella and Streptococcus. Give cefotaxime for 5d or until sensitivities are known. Consider prophylaxis in high risk patient or who have had a previous episode (norfloxacin)

Prognosis

• Overall 5 year survival is 50%
• Poor prognostic factors are – encephalitis, serum Na <110, serum albumin <25 and increased INR

Child-Pugh grading of cirrhosis

• Based on;
  • Bilirubin
  • Albumin
  • Prothrombin time
  • Ascites
  • Encephalopathy
• Grading can be used to predict prognosis and the quantify need for transplantation
• If the score is >8 there is increased risk of variceal bleeding