Cirrhosis
From Medical-Wiki
Cirrhosis is a histologic diagnosis that represents the final pathway for a variety of diseases that impart damage to hepatocytes. As such, clinical states associated with cirrhosis vary from patients who live relatively normal lives and have a barely altered life span to those in whom the disease follows a fulminant and fatal course. It is a condition responsible for 1.2% of all U.S. deaths—the 9th leading cause of death.
Contents |
Etiologies of cirrhosis
At one time, alcoholism was the most common cause of cirrhosis. Now, the leading cause is hepatitis C. Another growing cause of cirrhosis is nonalcoholic fatty liver disease (NAFLD). Approximately one third of Americans have NAFLD, and 2-3% of Americans have nonalcoholic steatohepatitis (NASH). This is characterized by fat deposition in the hepatocyte and is accompanied by inflammation and fibrosis. NAFLD is associated with obesity, diabetes, and hypertriglyceridemia, and has recently been demonstrated as leading to cirrhosis, though at one time this was thought not to be true.
A list of the most common causes of cirrhosis in the U.S. includes hepatitis C (26%), alcoholic liver disease (21%), hepatitis C plus alcoholic liver disease (15%), cryptogenic cirrhosis (18%), hepatitis B, which may be coincident with hepatitis D (15%), and miscellaneous causes(5%).
The miscellaneous causes include autoimmune hepatitis, primary biliary cirrhosis, secondary biliary cirrhosis, primary sclerosing cholangitis, hemochromatosis, Wilson disease, alpha-1 antitrypsin deficiency, granulomatous disease, e.g., sarcoidosis, type IV glycogen storage disease, drug-induced liver disease, e.g., methotrexate, alpha methyldopa, amiodarone, venous outflow obstruction e.g., Budd-Chiari syndrome, chronic right-sided heart failure, and tricuspid regurgitation. [1]
Morbidity with cirrhosis
Since cirrhosis is an end-stage disease, it is often a silent partner to whatever is its primary cause.
Well-compensated cirrhosis can present as anorexia and weight loss, weakness, fatigue, and even osteoporosis as a result of vitamin D malabsorption.
Decompensated disease can present as ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, variceal bleeding from portal hypertension, jaundice, pruritus, lower tract gastrointestinal bleeding, coagulopathy, increasing abdominal girth, and mental status changes.
Diagnosing cirrhosis
Physical findings
Physical findings include ascites, vascular spiders (spider angiomata, spider telangiectasias), asterixis, clubbing and hypertrophic osteoarthropathy, the so-called Cruveilhier-Baumgarten murmur—a venous hum in patients with portal hypertension, gynecomastia, jaundice , Kayser-Fleischer rings (found with Wilson disease), palmar erythema, scleral icterus, splenomegaly, and testicular atrophy. [2]
Laboratory findings
Since cirrhosis is a consequence of other diseases, there is no serologic test that confirms its diagnosis. Indeed, the most severe cases of cirrhosis may be accompanied by unimpressive or even normal liver function tests. There simply are not enough hepatocytes left to reflect an active process.
A laboratory investigation of suspected cirrhosis should thus be a pursuit of the associated diseases. Viral hepatitis serologies are the first factors that should be checked. If these are negative, then a work-up should include, when indicated clinically, antinuclear antibodies test and/or anti-smooth muscle antibody tests for autoimmune hepatitis; fasting transferrin saturation level or unsaturated iron-binding capacity and ferritin level for hereditary hemochromatosis. Serum ceruloplasmin and copper levels for Wilson disease; and antitrypsin (A1AT) levels in patients with chronic hepatic injury and no other apparent cause to evaluate AAT deficiency. Chronic cholestasis should suggest primary biliary cirrhosis or primary sclerosing cholangitis. [3]
Radiological signs of cirrhosis
Ultrasound should be the first line form of imaging used to evaluate a cirrhotic liver. It is the least expensive means of imaging, offers an assessment of the liver’s size, and if a small probe is used, a reasonable view of hepatic configuration. [4]
However, since cirrhosis is the most significant risk factor for hepatocellular carcinoma (HCC), CT was recently evaluated as a means of screening for HCC. The conclusion was, “Studies in patients with cirrhosis suggest that CT may be a more sensitive test for HCC than ultrasound or AFP more than 20 ug/L.” [5]
Complications of cirrhosis
Complications of cirrhosis are myriad and each one requires specific attention. When they occur together, they can represent a therapeutic nightmare. The major complications are ascites, renal dysfunction, hepatorenal syndrome, bacterial peritonitis, hepatic encephalopathy, coagulopathy, esophageal varices, and HCC.
Management of cirrhosis
Conservative management of cirrhosis must include nutritional counseling, management of ascites, management of esophageal varices, management of coagulopathies, monitoring for HCC, and monitoring of basic liver functions. [6]
The ultimate treatment is liver transplant. This is an area whose success rate has soared in the last decade. It is also an area of significant controversy relative to indications, cost, and role in patients with significant comorbid conditions. [7]
Keywords: CIRRHOSIS end-stage liver disease, ESLD, end stage liver disease, end-stage liver failure, end stage liver failure, ESLF, alcoholism, cirrhotic liver, chronic liver disease, chronic liver failure
