LIVER
CIRRHOSIS
Lecture by : Professor Sim Kong
Subject : Medical Therapeutics 1
Nortun University Group 2
Faculty of Health Sciences NU Topic : 6
Group Members
1. Sim Sokhieng 10. Sang Phoktin
2. Leak Chaney 11. Chann Sreypheak
3. Roueb Soneta 12.Lon Phalla
4. Nha Nit 13. Lay Meas Lymeng
5. Lay Noroneath 14. Sokchea Virak
6. Hoeurn Channy 15.Proum Sreyneath
7. Tep Muny 16.Om Chanvisal
8. Ban Kimsor 17.Bonath Sopheaktra
9. Bet Seyha 18.Chheng Soknin
CONTENTS
1. Definition
2. Anatomy and Physiology
3. Etiology
4. Pathogenesis
5. Signs and symptoms
6. Physical examination
7. Investigation
8. Complications
9. Treatment
1.DEFINITON
Liver Cirrhosis is late stage liver disease, in which
healthy liver tissue has been gradually replaced with
scar tissue. This is a result of long-term, chronic
hepatitis. Hepatitis is inflammation in your liver, which
has many causes. When inflammation is ongoing, your
liver attempts to repair itself by scarring. But too much
scar tissue prevents your liver from working properly.
The end stage is chronic liver failure.
2.ANATOMY AND PHYSIOLOGY
2.ANATOMY AND PHYSIOLOGY
3.ETIOLOGY
Common Causes of Cirrhosis
Alcohol abuse
Viral hepatitis(Chronic hepatitis B,C,and D)
The associated causes of cirrhosis
Non alcoholic steatohepatitis
Cardiac Cirrhosis
Chronic right-sided heart failure
Constrictive pericarditis
Drug-induced liver injury (DILI)
Autoimmune hepatitis
Primary biliary cirrhosis
Hemochromatosis (Primary and Secondary)
Wilson’s disease
Alpha1-Antitrypsin deficiency
4.PATHOGENESIS
1.Alcoholic
2.Hepatitis
THE PATHOGENESIS
The stage of alcohol liver disease
1.alcohol related fatty liver
2. Alcohol related hepatitis
3. Cirrhosis
THE PATHOGENESIS
Irreversible chronic injury of hepatic
parenchyma
Extensive fibrosis distortion of the
hepatic architecture
formation of regenerative nodules
The pathogenesis
5.SIGNS AND SYMPTOMS
➢ Signs of hepatocellular insufficiency
• Jaundice
• Ascites
• Hepatic encephalopathy
• Spider angioma
• Gastrointestinal symptom
• Coagulopathy
• Endocrine and metabolic change
• Palmar erythema
• Pitting Edema
• Nail change
Signs Portal Hypertension
➢ Upper Gi tract bleeding
• Esophageal varices rupture
• Gastric varices rupture
• Hematemesis
➢ Lower Gi tract bleeding
• Colon varices rupture
• Rectal varices rupture
➢ Splenomegaly
• Thrombocytopenia
• Leukopenia
• Anemia
➢ Caput medusae
6.PHYSICAL EXAMINATION
General Appearance:
• Cachexia (muscle wasting, weight loss)
• Jaundice (yellowish discoloration of skin and sclera)
• Fatigue and weakness
Vital Signs:
• Hypotension (due to peripheral vasodilation)
• Tachycardia (compensatory response to low systemic vascular
resistance)
Skin Findings:
• Jaundice (bilirubin accumulation)
• Spider angiomas (dilated blood vessels, usually on the upper chest,
face, and arms)
• Palmar erythema (reddening of the palms)
• Edema ( due to hypoalbuminemia )
Palmar erythema
Spider angiomas
Abdomen:
• Splenomegaly (due to portal hypertension)
• Ascites (shifting dullness, fluid wave)
• Caput medusae (dilated abdominal veins)
Caput medusae
Neurologic Findings:
• Hepatic encephalopathy:
• Confusion, lethargy, coma (in severe cases)
• Asterixis (flapping tremor when wrists are extended)
• Hyperreflexia
Hyperreflexia
7.PARACLINICAL
7.1 Laboratory tests
-Hemogram test: thrombocytopenia,
leukopenia
-Liver function tests :
.Alanine transaminase (ALT).
.Aspartate transaminase (AST).
. Prothrombin Time (PT).
.Alkaline phosphatase (ALP).
7.PARACLINICAL
7.1 Laboratory tests
-Liver function tests:
.Gamma-glutamyl transferase (GGT)
.Serum bilirubin.
.Total protein and albumin.
7.PARACLINICAL
7.1 Laboratory tests
. HBsAg.
.HBeAg.
.HBcAg.
.Ag.HCV.
. Glucose
.Alpha-fetoprotein (AFP):HCC.
7.PARACLINICAL
7.PARACLINICAL
7.2 Dianostic imagine
>Esophagogastroduodenoscopy(EGD)
>Fibroscan
>Abdomen ultrasound
>CT scan
>MRI.
7.PARACLINICAL
7.2 Dianostic imagine
>Esophagogastroduodeoscopy(EGD)
.Esophageal varies
.Portal Hypertension
7.PARACLINICAL
7.2 Dianostic imagine
> Fibroscan
7.PARACLINICAL
7.2 Dianostic imagine
> Abdomen ultrasound
7.PARACLINICAL
7.2 Dianostic imagine
> CT scan
7.PARACLINICAL
7.2 Dianostic imagine
>MRI
7.PARACLINICAL
7.3 Liver biopsy
.Liver biopsy is considered the gold
standard for cirrhosis and staging of
fibrosis.
8.COMPLICATIONS
Ascites
Diagnosis
Abdominal distension
Shifting Dullness
Fluid wave test
8. COMPLICATION
❑Spontaneous Bacterial Peritonitis (SBP)
•SBP(urgent vital +++): 10 to 30% of patients with
ascites hospitalized
•Manifestation et diagnostic:
•Fever, abdominal pain, diarrhea, encephalopathy...
•ascitePNN > 250/mm³
8.COMPLICATION
❑Gi bleeding
➢Upper Gi tract bleeding
•Esophageal varices rupture
•Gastric varices rupture
•Hematemesis
➢Lower Gi tract bleeding
•Colon varices rupture
•Rectal varices rupture
❑Diagnosis
•Esophagogastroduodenoscopy (EGD)
❑Treatment
•Endoscopic Variceal Ligation
•Beta blocker (prevention)
8.COMPLICATION
Hepatic Encephalopathy
•Is a serious condition that results from liver
dysfunction .Cause by hyperammonia.
8.COMPLICATION
Hepatorenal Syndrome
▷ Reduction in GFR often clinically masked
▷ Prognosis is poor unless hepatic function
improves
▷ Nephrotoxic agents and overdiuresis can
precipitate HRS.
8.COMPLICATION
Portopulmonary HTN
▷ Refers to the presence of pulmonary
hypertension in the coexistent portal
hypertension
► Prevalence in cirrhotic patients is
approximately 2 percent
▷ Diagnosis:
► Suggested by echocardiography
▷ Confirmed by right heart catheterization.
8.COMPLICATION
Hepatic Hydrothorax
►Pleural effusion in a patient with Cirrhosis and no evidence
of underlying cardiopulmonary disease ▷ Movement of ascitic
fluid into the pleuis ral space through defects in the
diaphragm, and usually right-sided Diagnosis -pleural fluid
analysis
▷ reveals a transudative fluid
▷ serum to fluid albumin gradient greater than 1.1
8.COMPLICATION
Hepatic hydrothorax
▷ Confirmatory study
▷ Scintigraphic studies demonstrate tracer in the Chest cavity
after injection into the peritoneal cavity
▷ Treatment options
▷ diuretic therapy
▷ periodic thoracentesis
▷ TIPS (Transjugular Intrahepatic Portosystemic-Shunt)
8.COMPLICATION
Hepatocellular Carcinoma
▷ Patients with cirrhosis have a markedly increased risk of
developing hepatocellular carcinoma
►▷ Incidence in well compensated Cirrhosis is approximately
3 percent per year
8.COMPLICATION
Hepatocellular Carcinoma
Symptoms are largely due to mass effect from the tumor
Pain, early satiety, obstructive jaundice, and a palpable mass
Serum AFP greater than 500 micrograms/l in a patient with
cirrhosis are virtually diagnostic
Median survival following diagnosis is approximately 6 to 20
months
8.COMPLICATION
Hepatocellular Carcinoma
Symptoms are largely due to mass effect from the tumor
Pain, early satiety, obstructive jaundice, and a palpable mass
Serum AFP greater than 500 micrograms/l in a patient with
cirrhosis are virtually diagnostic
Median survival following diagnosis is approximately 6 to 20
months
Treatment
treat underlying disorder
decrease insults (e.g. alcohol cessation, hepatotoxic drugs, immunize for Hep A and B if non-
immune)
follow patient for complications (esophageal varices, ascites, HCC defines stage 2 cirrhosis)
prognosis: Child-Pugh Score and MELD score
liver transplantation for end-stage disease if no alcohol for >6 mo; use MELD score
t
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