Cirrhosis of Liver is a diffuse disease of liver characterized by fibrosis, formation of nodules, and disruption of parenchymal architecture of the entire liver. The diseases that lead to cirrhosis do so because they injure and kill liver cells, and the inflammation and repair that is associated with the dying liver cells causes scar tissue to form. The liver cells that do not die multiply in an attempt to replace the cells that have died. This results in clusters of newly-formed liver cells (regenerative nodules) within the scar tissue. There are many causes of cirrhosis; they include chemicals (such as alcohol, fat, and certain medications), viruses, toxic metals (such as iron and copper that accumulate in the liver as a result of genetic diseases), and autoimmune liver disease in which the body's immune system attacks the liver.
Classification
1. Aetiological classification :
a. Alcoholic cirrhosis
b. Post hepatitis (HBV, HCV) cirrhosis
c. Cardiac cirrhosis
d. Metabolic cirrhosis : Wilson's disease
e. Cryptogenic cirrhosis
f. Cirrhosis in Haemochromatosis
2. Morphological classification :
a. Micro nodular cirrhosis : small < 3mm, regular
b. Macro nodular cirrhosis : large > 3mm
c. Mixed cirrhosis
Clinical Features
Symptoms :-
1. Weakness, fatigue
2. Weight loss
3. Anorexia
4. Nausea, vomiting
5. Upper abdominal discomfort
6. Abdominal distension
7. Haematemesis, malaena
8. Loss of libido
9. Menstrual irregularities in Women
Signs :-
1. Face :
- Spider navae
- Hapatic facies : sunken eye, mild jaundice
- Fetor hepaticus : fouls smell from mouth
2. Hand :
- Digital clubbing
- Palmar erythema
- Leuconychia
3. Trunk :
- Scanty axillary hair
- Gynaecomastia (Men)
- Breast atrophy (Women)
4. Abdomen :
- Hepatomegaly
- Ascites, caput medusae
- Scanty pubic hair
5. Lower limb : edema
Differential Diagnosis
In the patient presenting with ascites, consider :
- abdominal malignancy
- Cardiac failure
-Peritoneal TB
- Constrictive pericarditis
Investigations
1. Liver Function Test
- Serum bilirubin : raised
- Plasma aminotransferase
- Plasma alkaline phosphatase : raised
- Plasma albumin : decreased
- Prolonged Prothrombin time
2. Liver biopsy - diagnostic
3. Viral markers : HBsAg, Anti HCV
4. Ultra sonogram of Hepatobiliary system
5. Chest X-ray
Treatment
Treatment of cirrhosis includes :
1. Preventing further damage to the liver :
- Consume a balanced diet and one multivitamin daily.
- Avoid consumption of alcohol.
- Avoid nonsteroidal anti-inflammatory drugs (NSAIDs, e.g., ibuprofen).
- Suppress the immune system with drugs such as prednisone and azathioprine (Imuran) to decrease inflammation of the liver in autoimmune hepatitis.
2. Treating the complications of cirrhosis :
- Edema and ascites
- Bleeding from varices
- Hepatic encephalopathy
- Hypersplenism
- Spontaneous bacterial peritonitis (SBP)
3. Preventing liver cancer or detecting it early :
- Several types of liver disease that cause cirrhosis are associated with a particularly high incidence of liver cancer, for example, hepatitis B and C, and it would be useful to screen for liver cancer since early surgical treatment or transplantation of the liver can cure the patient of cancer.
- The difficulty is that the methods available for screening are only partially effective, identifying at best only 50% of patients at a curable stage of their cancer. Despite the partial effectiveness of screening, most patients with cirrhosis, particularly hepatitis B and C, are screened yearly or every six months with ultrasound examination of the liver and measurements of cancer-produced proteins in the blood, e.g. alpha fetoprotein.
4. Liver transplantation :
- Cirrhosis is irreversible. Many patients' liver function will gradually worsen despite treatment and complications of cirrhosis will increase and become difficult to treat. Therefore, when cirrhosis is far advanced, liver transplantation often is the only option for treatment.
Complications
1. Spontaneous bacterial peritonitis (SBP)
2. Edema and ascites
3. Hepatic encephalopathy
4. Hepatorenal syndrome
5. Bleeding from esophageal varices
6. Hepatopulmonary syndrome
7. Liver cancer (hepatocellular carcinoma)
8. Hypersplenism
Classification
1. Aetiological classification :
a. Alcoholic cirrhosis
b. Post hepatitis (HBV, HCV) cirrhosis
c. Cardiac cirrhosis
d. Metabolic cirrhosis : Wilson's disease
e. Cryptogenic cirrhosis
f. Cirrhosis in Haemochromatosis
2. Morphological classification :
a. Micro nodular cirrhosis : small < 3mm, regular
b. Macro nodular cirrhosis : large > 3mm
c. Mixed cirrhosis
Clinical Features
Symptoms :-
1. Weakness, fatigue
2. Weight loss
3. Anorexia
4. Nausea, vomiting
5. Upper abdominal discomfort
6. Abdominal distension
7. Haematemesis, malaena
8. Loss of libido
9. Menstrual irregularities in Women
Signs :-
1. Face :
- Spider navae
- Hapatic facies : sunken eye, mild jaundice
- Fetor hepaticus : fouls smell from mouth
2. Hand :
- Digital clubbing
- Palmar erythema
- Leuconychia
3. Trunk :
- Scanty axillary hair
- Gynaecomastia (Men)
- Breast atrophy (Women)
4. Abdomen :
- Hepatomegaly
- Ascites, caput medusae
- Scanty pubic hair
5. Lower limb : edema
Differential Diagnosis
In the patient presenting with ascites, consider :
- abdominal malignancy
- Cardiac failure
-Peritoneal TB
- Constrictive pericarditis
Investigations
1. Liver Function Test
- Serum bilirubin : raised
- Plasma aminotransferase
- Plasma alkaline phosphatase : raised
- Plasma albumin : decreased
- Prolonged Prothrombin time
2. Liver biopsy - diagnostic
3. Viral markers : HBsAg, Anti HCV
4. Ultra sonogram of Hepatobiliary system
5. Chest X-ray
Treatment
Treatment of cirrhosis includes :
1. Preventing further damage to the liver :
- Consume a balanced diet and one multivitamin daily.
- Avoid consumption of alcohol.
- Avoid nonsteroidal anti-inflammatory drugs (NSAIDs, e.g., ibuprofen).
- Suppress the immune system with drugs such as prednisone and azathioprine (Imuran) to decrease inflammation of the liver in autoimmune hepatitis.
2. Treating the complications of cirrhosis :
- Edema and ascites
- Bleeding from varices
- Hepatic encephalopathy
- Hypersplenism
- Spontaneous bacterial peritonitis (SBP)
3. Preventing liver cancer or detecting it early :
- Several types of liver disease that cause cirrhosis are associated with a particularly high incidence of liver cancer, for example, hepatitis B and C, and it would be useful to screen for liver cancer since early surgical treatment or transplantation of the liver can cure the patient of cancer.
- The difficulty is that the methods available for screening are only partially effective, identifying at best only 50% of patients at a curable stage of their cancer. Despite the partial effectiveness of screening, most patients with cirrhosis, particularly hepatitis B and C, are screened yearly or every six months with ultrasound examination of the liver and measurements of cancer-produced proteins in the blood, e.g. alpha fetoprotein.
4. Liver transplantation :
- Cirrhosis is irreversible. Many patients' liver function will gradually worsen despite treatment and complications of cirrhosis will increase and become difficult to treat. Therefore, when cirrhosis is far advanced, liver transplantation often is the only option for treatment.
Complications
1. Spontaneous bacterial peritonitis (SBP)
2. Edema and ascites
3. Hepatic encephalopathy
4. Hepatorenal syndrome
5. Bleeding from esophageal varices
6. Hepatopulmonary syndrome
7. Liver cancer (hepatocellular carcinoma)
8. Hypersplenism
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