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