Cirrhosis: Difference between revisions

Latest revision as of 02:23, 27 November 2021

Background

End-stage hepatic fibrosis with hepatic dysfunction

Epidemiology

25% of Canadians have NAFLD

Etiology

Infectious
- Chronic hepatitis B
- Chronic hepatitis C
- Brucellosis, echinococcosis, syphilis
Toxins and drugs
- Alcohol
- Medications: isoniazid, methotrexate
Autoimmune/inflammatory
- Autoimmune hepatitis (AIH)
- Primary biliary cirrhosis (PBC)
- Primary sclerosing cholangitis
- Celiac disease
Metabolic
Other

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
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

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 vulnificus infection in cirrhosis)

Prognosis

Median survival 1.6 years after admission for decompensated cirrhosis

@@ Line 1: / Line 1: @@
-== Definition ==
+== Background ==
 * End-stage hepatic fibrosis with hepatic dysfunction
-== Epidemiology ==
+=== Epidemiology ===
 * 25% of Canadians have NAFLD
-== Etiology ==
+=== Etiology ===
 * Infectious
-** Chronic Hepatitis B
+** Chronic [[hepatitis B]]
-** '''Chronic Hepatitis C'''
+** '''Chronic [[hepatitis C]]'''
+**[[Brucellosis]], [[echinococcosis]], [[syphilis]]
-* Toxin
+* Toxins and drugs
 ** '''Alcohol'''
+**Medications: [[isoniazid]], [[methotrexate]]
 * Autoimmune/inflammatory
-** Autoimmune hepatitis (AIH)
+** [[Autoimmune hepatitis]] (AIH)
-** Primary biliary cirrhosis (PBC)
+** [[Primary biliary cirrhosis]] (PBC)
+**[[Primary sclerosing cholangitis]]
+**[[Celiac disease]]
 * 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 ==
@@ Line 35: / Line 45: @@
 * 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 ==
 * Decompensated
-** Rule out [[Spontaneous bacterial peritonitis]] with every episode
+** Rule out [[spontaneous bacterial peritonitis]] with every episode
 * Ascites
 ** Furosemide 40 and spironolactone 100 (max 160/400)
@@ Line 59: / Line 80: @@
 === 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 ==