Cirrhosis - Revision history

Aidan: /* Management */

2021-11-27T02:23:44Z

Management

← Older revision		Revision as of 02:23, 27 November 2021
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	=== Preventative Care ===		=== Preventative Care ===

	* Avoid raw oysters (high risk of ''Vibrio ~~vulnificans''~~ infection in cirrhosis)		* Avoid raw oysters (high risk of [[Vibrio vulnificus]] infection in cirrhosis)

	== Prognosis ==		== Prognosis ==

Aidan: /* Management */

2021-11-27T02:23:04Z

Management

← Older revision		Revision as of 02:23, 27 November 2021
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	* Decompensated		* Decompensated
	** Rule out [[~~Spontaneous~~ bacterial peritonitis]] with every episode		** Rule out [[spontaneous bacterial peritonitis]] with every episode
	* Ascites		* Ascites
	** Furosemide 40 and spironolactone 100 (max 160/400)		** Furosemide 40 and spironolactone 100 (max 160/400)

Aidan at 02:21, 27 November 2021

2021-11-27T02:21:25Z

← Older revision		Revision as of 02:21, 27 November 2021
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	== ~~Definition~~ ==		== Background ==

	* End-stage hepatic fibrosis with hepatic dysfunction		* End-stage hepatic fibrosis with hepatic dysfunction

	== Epidemiology ==		=== Epidemiology ===

	* 25% of Canadians have NAFLD		* 25% of Canadians have NAFLD

	== Etiology ==		=== Etiology ===

	* Infectious		* Infectious
	** Chronic ~~Hepatitis~~ B		** Chronic [[hepatitis B]]
	** '''Chronic ~~Hepatitis~~ C'''		** '''Chronic [[hepatitis C]]'''
			**[[Brucellosis]], [[echinococcosis]], [[syphilis]]
	* Toxin
			* Toxins and drugs
	** '''Alcohol'''		** '''Alcohol'''
			**Medications: [[isoniazid]], [[methotrexate]]
	* Autoimmune/inflammatory		* Autoimmune/inflammatory
	** Autoimmune hepatitis (AIH)		** [[Autoimmune hepatitis]] (AIH)
	** Primary biliary cirrhosis (PBC)		** [[Primary biliary cirrhosis]] (PBC)
			**[[Primary sclerosing cholangitis]]
			**[[Celiac disease]]
	* Metabolic		* Metabolic
	** '''NASH'''		** '''[[NASH]]'''
	** Wilson's disease		** [[Wilson disease]]
			** [[Hereditary hemochromatosis]]
	** Hemochromatosis
	** ~~alpha~~-1 antitrypsin deficiency		** [[α-1 antitrypsin deficiency]]
			*Other
			**Right-sided [[heart failure]]
			**[[Veno-occlusive disease]]
			**[[Hereditary hemorrhagic telangiectasia]]
			**[[Polycystic liver disease]]
			**[[Granulomatous liver disease]]

	== JAMA Rational Clinical Exam ==		== JAMA Rational Clinical Exam ==
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	* Lab abnormalities in liver failure, in order:		* Lab abnormalities in liver failure, in order:
	* Decrease in platelets		** Decrease in platelets
	* Increase in bilirubin		** Increase in bilirubin
	* Decrease in albumin		** Decrease in albumin
	* Increase in INR		** Increase in INR
			*Investigations for possible causes of cirrhosis include:
			**Liver ultrasound
			**Hepatitis B and C serologies
			**Ferritin and transferrin saturation, for [[hereditary hemochromatosis]]
			**Autoimmune serologies
			***ANA and anti-smooth muscle antibodies, for [[PSC]] and [[AIH]]
			***Anti-mitochondrial antibodies and anti-parietal cell antibodies, for [[PBC]]
			***Consider anti-LKM-1, for [[PSC]]
			**Quantitative immunoglobulins, for elevated IgM in [[PBC]] or [[hypergammaglobulinemia]] in [[AIH]]
			**Consider serum ceruloplasmin, for [[Wilson disease]]
			**Consider α-1 antitripsyin levels, for deficiency

	== Management ==		== Management ==

Maintenance script: Imported from text file

2020-07-04T01:17:28Z

Imported from text file

New page

== Definition ==

* End-stage hepatic fibrosis with hepatic dysfunction

== Epidemiology ==

* 25% of Canadians have NAFLD

== Etiology ==

* Infectious
** Chronic Hepatitis B
** '''Chronic Hepatitis C'''
* Toxin
** '''Alcohol'''
* Autoimmune/inflammatory
** Autoimmune hepatitis (AIH)
** Primary biliary cirrhosis (PBC)
* Metabolic
** '''NASH'''
** Wilson's disease
** Hemochromatosis
** alpha-1 antitrypsin deficiency

== JAMA Rational Clinical Exam ==

* Ascites (LR+ 7.2)
* Platelet count <160 (LR+ 6.3; LR- 0.29 if ≥160)
* Spider nevi (LR+ 4.3)
* Bonacini cirrhosis discriminant score >7 (LR+ 9.4)
* Lok index <0.2 (LR- 0.09)
* Absence of hepatomegaly (LR- 0.37)

== Investigations ==

* Lab abnormalities in liver failure, in order:
* Decrease in platelets
* Increase in bilirubin
* Decrease in albumin
* Increase in INR

== Management ==

* Decompensated
** Rule out [[Spontaneous bacterial peritonitis]] with every episode
* Ascites
** Furosemide 40 and spironolactone 100 (max 160/400)
** Serial therapeutic paracentesis
*** Small-volume (<4-5L) does not need albumin
*** Large-volume needs 6-8 g of 25% albumin per litre removed
** Avoid indwelling drain
** TIPS can be considered but precipitates encephalopathy
* Prophylaxis/chronic
** SBP: maybe?
** Encephalopathy: no role for primary prophylaxis
** Surveillance with upper endoscopy
** Ultrasound q6mo for HCC

=== Preventative Care ===

* Avoid raw oysters (high risk of ''Vibrio vulnificans'' infection in cirrhosis)

== Prognosis ==

* Median survival 1.6 years after admission for decompensated cirrhosis

[[Category:Gastroenterology]]