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Cirrhosis of the Liver and Its Complications

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by

Itai Strominger

on 27 June 2013

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Transcript of Cirrhosis of the Liver and Its Complications

Cirrhosis of the Liver and Its Complications
What is it cirrhosis?
Prof. Iris Shai
The
irreversible end result

of
a variety of inflammatory, toxic, metabolic and congestive
damages to the liver
,
leads to bands of
fibrous tissue surrounding the nodules

of regenerating hepatocytes
.

Prof. Iris Shai says it's OK
Often asymptomatic
- incidentally diagnosis by physical/lab/radiology tests
Specific complications of cirrhosis:
Variceal bleeding
Ascites
Spontaneous bacterial peritonitis
Hepatic encephalopathy
To summary
Early Detection (history, specific signs)


Prevention & Treatment

Bands of fibrous tissue
Toxic damage
Congestive damage
Inflammatory damage
Small nodules - alcoholic cirrhosis
Big nodules - chronic active hepatitis
Portal hypertension

Intrahepatic shunting
Results of cirrhosis
Cutaneous
Endocrine
Gastrointestinal
Hematologic
Neurologic

Clinical manifestation
Gold Standard - Liver biopsy
Diagnosis
Clinical features
Ascites
Variceal bleeding
Metabolism damage
Often nonspecific
(fatigue, weakness, weight gain or loss, anorexia, nausea and more)
Asterixis, gynecomastia, caput medusae, ascites,


And:
Muehrcke's lines
Terry's nails
Causes of cirrhosis
Pathogenesis
Bands of fibrous tissue
Small nodules - alcoholic cirrhosis
Big nodules - chronic active hepatitis
Liver dysfunction
Portal hypertension
Hepatomegaly,
Hepatocellular carcinoma
Fatigue
weakness
weight loss
(up to anorexia)
Pathogenesis
Signs & symptoms
General
Gastrointestinal
Abdominal pain

Gastrointestinal
Abdominal swelling (ascites)
GI bleeding (Esophageal hemorrhage)
Hematologic
Anemia
Leukopenia
Thrombocytopenia
Due to hypersplenism secondary to PH:
Abnormal estrogen & androgen metabolism
Cutaneous
Palmar erythema
Spider angiomas
Endocrine
Due to decreased synthesis of coagulation factors :
Ecchymosis
Gynecomastia
Testicular atrophy
Decreased libido
Decreased body hair (in men)
Menstrual irregularities
(in women)
Hepatocellular dysfunction
&
portosystemic shunting
Cutaneous
Decreased bilirubin excertion:
Juandice
Caput medusae
Cutaneous
Porosystemic shunting due to PH:
Hematologic
Altered sleep pattern
Somnolence (and even coma)
Confusion
Asterixis
Neurologic
Liver Dysfunction
Lab
Portalי Hypertension
HyperSplenism

Anemia
Thrombocytopenia
GI Blood Loss
Leukopenia
Blood Urea Nitrogen
Hyper
bilirubin
emia
Serum Ammonia
Hypo
albumin
emia
Prothrombin time
Impaired protein synthesis
Pathogenesis
Lab findings
Radiology
Ultrasound (w/wo doppler of portal & hepatic venous vasculature)
CT
MRI
Radiologic options:
Radiology findings:
Structural changes
(enlargement of left & caudate lobes)
Portal hypertension features (ascites, varices, splenomegaly)
Major complications
Questions:
Portal Hypertension
Hepatocellular Carcinoma (HCC)
Hepatocellular Dysfunction
Cirrhosis
Vascular disease of the liver... what is the connection?
Impaired protein synthesis
Bilirubin
Albumin
Coagulation factors
hepatic detoxification
HepatoRenal Syndrome
Spontaneous Bacterial Peritonitis
Vericeal Hemorrhage
Ascites
HepatoPulmonary Syndrome
Hepatic Encephalopathy
How do we diagnose PH?
HVPG (Hepatic Venous Pressure Gradient)
normal HVPG:
HVPG < 5 mmHg
OK, so whats the problem?
Leads to:
Decreased peripheral resistance

Increased Na and H2O, Plasma volume

Increased Cardiac output & Splanchnic blood flow
Nitric Oxide mediated mechanism
Compensation mechanism:
HVPG > 12 mmHG
In about 20% of patients each year
each episode = 23% mortality rate

Prevention & Treatment:
beta-blockers/somatostatin/Endoscopy
Didn't work?
Surgery or Liver transplant
Accumulation of fluid in the peritoneal cavity.
Treatment:
Low sodium diet
Aldosteron antagonist + diuretic drug = effective in 90% of patients
Cirrhosis = The leading cause for ascites.
Diagnosis = by shifting dullness
Due to Na, H2O retention, and splanchnic vasodilatation
Infection of the ascitic fluid.
Diagnosis:
Silent
or
Fever, abdominal pain, peritoneal irritation
or
Heptic Encephalopathy or Renal insufficiency
Most common - by E. coli & Klebsielle
Lab:
Ascitic fluid PMNs > 250 cells/ml
Culture

Treatment:
Antibiotics
Functional renal failure as a result of serious liver disease.
Treatment:
Treating the peritonitis & hepatitis as soon as possible
Vasopressin analogous + I.V. Albumin
The kidneys remain functional!
Due to
severe cortical vasoconstriction
The result -
decreased urine production
Mortality is high
Neuropsychiatric syndrome which caused by liver complication.
Pathogenesis:
High Ammonia &/ toxin levels

Acute:
Due to cerebral edema
High mortality!

Chronic:
Normally with cirrhosis
Reversible.
Treatment:
Enemas
Antibiotics

Gas exchange abnormalities, Occurs in about 20% of cirrhosis patients.
Clinical features:
Subclinical abnormalities threw
hypoxemia
As a result of intrapulmonary vascular dilation. -
Nitric Oxide
Treatment:
Liver transplatation
- results usually in complete reversal.
Most cases of HCC are secondary to either a viral hepatitis infection (HBV/HCV) or cirrhosis.
Hepatocellular regeneration
leads to cancer

Twice as common in men

Detection - Radiology
.
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