CIRRHOSIS OF LIVERPORTAL HYPERTENSION

HEPATIC ENCHEPALOPATHY

PART-ONE1 TO 21 slides

Definition of cirrhosis

Cirrhosis is derived from Greek word kirros=orange or tawny and osis=condition

-WHO definition :a diffuse process characterized by liver necrosis and fibrosis and conversion of normal liver architechture into structurally abnormal nodules that lack normal lobular organisation.

CAUSES OF LIVER CIRRHOSIS

-Infections:post hepatitic cirrhosis(B,D,C).-Toxins:Alcohol.-Cholestatic liver disease:PBC,PSC…-Autoimmune diseases:autoimmune hepatitis.-Vascular disorders: cardiac cirrhosis,Budd-Chiari

syndrome ,Veno occlusive disease-Metabolic and genetic :Wilson

disease ,hemochromatosis,alpha 1- antitrypsin deficiency

-Non alcoholic steato hepatitis(NASH). Cryptogenic.

Pathology of cirrhosis

-nodularity(regenerating nodules).-fibrosis(deposition of dense fibrous septa)-

fragmentation of sample.-abnormal liver architecture-hepatocyte

abnormalities:pleomorphism,dysplasia,hyperplasia

-Gross pathology:irregular surface ,yellowish colour,small,firm

CirrhosisCirrhosisNormalNormal

Nodules surrounded by fibrous tissueNodules surrounded by fibrous tissue

HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVER

HISTOLOGICAL IMAGE OF CIRRHOSIS

FibrosisFibrosis

Regenerative noduleRegenerative nodule

CompensatedcirrhosisCompensatedcirrhosis

DecompensatedcirrhosisDecompensatedcirrhosis DeathDeath

Chronic liver disease

Chronic liver disease

Natural History of Chronic Liver Disease

Development of complications:

Development of complications:

· Variceal hemorrhage

· Ascites· Encephalopathy· Jaundice

· Variceal hemorrhage

· Ascites· Encephalopathy· Jaundice

NATURAL HISTORY OF CHRONIC LIVER DISEASE

CLINICAL FEATURES• Hepatomegaly (although liver may also be small) • Jaundice • Ascites • Circulatory changes

– Spider telangiectasia, palmar erythema, cyanosis • Endocrine changes

– Loss of libido, hair loss – Men: gynaecomastia, testicular atrophy, impotence – Women: breast atrophy, irregular menses, amenorrhoea

• Haemorrhagic tendency – Bruises, purpura, epistaxis, menorrhagia

• Portal hypertension – Splenomegaly, collateral vessels, variceal bleeding, fetor hepaticus

• Hepatic (portosystemic) encephalopathy • Other features

– Pigmentation, digital clubbing

Liver insufficiencyLiver insufficiency

Variceal hemorrhageVariceal hemorrhage

Complications of Cirrhosis Result from Portal Hypertension or Liver InsufficiencyComplications of Cirrhosis Result from Portal Hypertension or Liver Insufficiency

CirrhosisCirrhosisAscitesAscites

EncephalopathyEncephalopathy

JaundiceJaundice

Portal hypertensionPortal hypertension Spontaneous

bacterial peritonitis

Spontaneous bacterial peritonitis

Hepatorenal syndromeHepatorenal syndrome

COMPLICATIONS OF CIRRHOSIS

Diagnosis of cirrhosis

• clinical+laboratory+radiologic+liver biopsy

In Whom Should We Suspect Cirrhosis?In Whom Should We Suspect Cirrhosis?

· Any patient with chronic liver disease· Chronic abnormal aminotransferases and/or

alkaline phosphatase

· Physical exam findings· Stigmata of chronic liver disease (muscle

wasting, vascular spiders, palmar erythema)· Palpable left lobe of the liver· Small liver span· Splenomegaly· Signs of decompensation (jaundice, ascites,

asterixis)

· Any patient with chronic liver disease· Chronic abnormal aminotransferases and/or

alkaline phosphatase

· Physical exam findings· Stigmata of chronic liver disease (muscle

wasting, vascular spiders, palmar erythema)· Palpable left lobe of the liver· Small liver span· Splenomegaly· Signs of decompensation (jaundice, ascites,

asterixis)

DIAGNOSIS OF CIRRHOSIS – CLINICAL FINDINGS

Laboratory· Liver insufficiency

· Low albumin (< 3.8 g/dL)· Prolonged prothrombin time (INR > 1.3)· High bilirubin (> 1.5 mg/dL)

· Portal hypertension· Low platelet count (< 175 x1000/ml)

· AST / ALT ratio > 1

Laboratory· Liver insufficiency

· Low albumin (< 3.8 g/dL)· Prolonged prothrombin time (INR > 1.3)· High bilirubin (> 1.5 mg/dL)

· Portal hypertension· Low platelet count (< 175 x1000/ml)

· AST / ALT ratio > 1

In Whom Should We Suspect Cirrhosis?In Whom Should We Suspect Cirrhosis?

DIAGNOSIS OF CIRRHOSIS – LABORATORY STUDIES

CT Scan in CirrhosisCT Scan in Cirrhosis

Liver with an irregular surfaceLiver with an irregular surface SplenomegalySplenomegalyCollateralsCollaterals

DIAGNOSIS OF CIRRHOSIS – CAT SCAN

NoNoYesYes

Diagnostic AlgorithmDiagnostic Algorithm

Patient with chronic liver disease and any of the following:· Variceal hemorrhage· Ascites· Hepatic encephalopathy

Patient with chronic liver disease and any of the following:· Variceal hemorrhage· Ascites· Hepatic encephalopathy

Liver biopsy not necessary for the diagnosis of cirrhosis

Liver biopsy not necessary for the diagnosis of cirrhosis

Physical findings:Enlarged left hepatic lobeSplenomegalyStigmata of chronic liver disease

Physical findings:Enlarged left hepatic lobeSplenomegalyStigmata of chronic liver disease

Laboratory findings:ThrombocytopeniaImpaired hepatic synthetic function

Laboratory findings:ThrombocytopeniaImpaired hepatic synthetic function

Radiological findings:· Small nodular liver· Intra-abdominal collaterals· Ascites· Splenomegaly· Colloid shift to spleen and/or bone marrow

Radiological findings:· Small nodular liver· Intra-abdominal collaterals· Ascites· Splenomegaly· Colloid shift to spleen and/or bone marrow

YesYes NoNo

YesYes NoNo

Liver biopsyLiver biopsy

DIAGNOSTIC ALGORITHM

Management of cirrhosis

-Specific treatment in some pre cirrhotic lesions: Wilson’s disease—Dpenicillamine,,hemochromatosis---phlebotomy,,antiviral drugs for chronic viral hepatitis

-in established cirrhosis---treatment of complications-screening for hepatocellular carcinoma-liver transplantation-maintenance of nutrition

CHILD-PUGH CLASSIFICATION OF PROGNOSIS IN CIRRHOSIS

Score 1 2 3Encephalopathy None Mild Marked

Bilirubin (mg/dl) < 2.0 2.0-3.0 > 3.0

Albumin (g/dl) > 3.5 3.0-3.5 < 3.0

Prothrombin time (seconds prolonged)

< 4 4-6 > 6

Ascites None Mild Marked

Add the individual scores:

< 7 = Child's A7-9 = Child's B> 9 = Child's C

MELD SCORE

• MELD = 3.8(SERUM BILIRUBIN –MG/DL)+11.2 IN INR + 9.6 IN SERUM CREATININE – MG/DL+ 6.4

PORTAL HYPERTENSION

Definition:it is an increase in portal venous pressure.

-normal portal pressure:5-10mmHg.-portal hypertension;>12mmHg-normal portal blood flow:1-1.5L/minute-- increased resistance to portal blood flow

+hyperdynamic circulation-----formation of porto systemic collaterals that diver blood to systemic circulation bypassing the liver

Mechanisms of Portal HypertensionMechanisms of Portal Hypertension

· Pressure (P) results from the interaction of resistance (R) and flow (F):

· Pressure (P) results from the interaction of resistance (R) and flow (F):

P = R x FP = R x F

· Portal hypertension can result from: · increase in resistance to portal flow

and/or · increase in portal venous inflow

· Portal hypertension can result from: · increase in resistance to portal flow

and/or · increase in portal venous inflow

MECHANISMS OF PORTAL HYPERTENSION