Liver cirrhosis Usama Ahmed Arafa MD Ass Professor

Liver cirrhosis Usama Ahmed Arafa, MD Ass. Professor of Internal Medicine

Definition

Liver cirrhosis is characterized by: 1 - Hepatocellular necrosis 2 - Hepatic fibrosis 3 - Regeneration nodules 4 - Loss of architecture

Normal Liver

Cirrhosis

Normal Liver Histology CV PT

Cirrhosis Fibrosis Regenerating Nodule

Etiology

Common causes • Chronic viral hepatitis: C, B ± D • Alcohol • Schistosomiasis (fibrosis not true LC) Less Common causes • Biliary cirrhosis: - primary - secondary • Autoimmune hepatitis • Hereditary: - Haemochromatosis - Wilson's disease - Alpha 1 antitrypsin deficiency

• Drugs (e. g. methotrexate) • Cystic fibrosis • Non-alcoholic fatty liver disease (NAFLD) • Glycogen storage disease • Veno-occlusive disease • Hepatic venous congestion • Budd-Chiari syndrome • Idiopathic (cryptogenic)

Pathogenesis

• Chronic injury to the liver results in inflammation, necrosis and, eventually, fibrosis. • Fibrosis is initiated by activation of the stellate cells.

• In the space of Disse, the normal matrix is replaced by collagen. Subendothelial fibrosis leads to loss of the endothelial fenestrations, and this impairs liver function. • There is accumulating evidence that liver fibrosis is reversible.

• Pathogenesis of fibrosis

Pathological Types

Micronodular cirrhosis: Regenerating nodules are usually less than 3 mm in size. This type is often caused by alcoholic or biliary cirrhosis. Macronodular cirrhosis: The nodules are of variable size and normal acini may be seen within the larger nodules. This type is often seen following previous hepatitis. A mixed picture: with small and large nodules is sometimes seen.

Micronodular cirrhosis

Micronodular cirrhosis:

Macronodular Cirrhosis

Symptoms and Signs

A- General manifestations • Wasting • Parotid enlargement • Hyperkinetic circulation • Increased susceptibility to infection

B- Skin manifestations • Spider nevi • Palmar erythema • Leuconychia • Dupuytren’s contractures • Xanthomas • Alternation of body hair distribution

C- Endocrinal manifestations • Gynecomastia • Testicular atrophy • Amenorrhea in females

Gynecomastia in cirrhosis

D- Abdominal manifestations • Hepatomegaly then shrinkage later • Splenomegaly • Prominent abdominal veins • Peptic ulcer disease • Chronic pancreatitis • Steatorrhea

Portosystemic anastomosis: Prominent abdominal veins.

E- Decompensation • Jaundice • Ascitis • Bleeding tendency • Hepatic encephalopathy

Physical signs in liver cirrhosis.

Investigations

Investigations for severity § Liver function. Serum albumin and prothrombin time are the best indicators of liver function. ■ Liver biochemistry. In most cases there is a slight elevation in the serum ALP and serum aminotransferases. ■ Serum electrolytes. A low sodium indicates severe liver disease.

Investigations for the etiology • • • Viral markers Serum autoantibodies Iron indices and ferritin Copper, ceruloplasmin Alpha 1 antitrypsin (Serum copper and alpha 1 antitrypsin should always be measured in young cirrhotics)

Others • Ultrasound examination. • CT scan. • MRI scan. • Endoscopy. • Liver biopsy.

Management

► Management is that of complications. ► Patients should have 6 -monthly ultrasound and serum AFP to detect the development of a hepatocellular carcinoma as early as possible. ► There is no treatment that will arrest or reverse the cirrhotic changes although progression may be halted by correcting the underlying cause.

► Patients with compensated cirrhosis should lead a normal life. ► The only dietary restriction is to reduce salt intake. ► Aspirin and NSAIDs should be avoided. ► Alcohol should be avoided.

LIVER TRANSPLANTATION ► This is an established treatment for a number of liver diseases. ► Shortage of donors is a major problem in all developed countries.

Course and Prognosis

Child's-Pugh classification Score • • • 1 Ascites None Encephalopathy None Bilirubin < 2 mg/d. L Albumin > 3. 5 (g/d. L) Prothrombin time < 4 seconds (Scores) Child's A (< 7) Child's B (7 -9) Child's C (10+) 1 -year survival 82 62 42 2 3 Mild 2 -3 3. 5 -2. 8 4 -6 Moderate/severe Marked >3 < 2. 8 >6 5 years 45 20 20 10 years 25 7 0

COMPLICATIONS AND EFFECTS OF CIRRHOSIS

► Portal hypertension and gastrointestinal haemorrhage ► Ascites ► Portosystemic encephalopathy ► Renal failure (hepatorenal syndrome) ► Hepatopulmonary syndrome ► Hepatocellular carcinoma ► Bacteraemias, infections ► Malnutrition

Ascites in Cirrhosis

Hepatocellular Carcinoma