Cirrhosis: Difference between revisions

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== Definition ==
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== Background ==
   
 
* End-stage hepatic fibrosis with hepatic dysfunction
  
* End-stage hepatic fibrosis with hepatic dysfunction
   
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== Epidemiology ==
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=== Epidemiology ===
   
 
* 25% of Canadians have NAFLD
  
* 25% of Canadians have NAFLD
   
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== Etiology ==
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=== Etiology ===
   
 
* Infectious
  
* Infectious
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** Chronic Hepatitis B
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** Chronic [[hepatitis B]]
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** '''Chronic Hepatitis C'''
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** '''Chronic [[hepatitis C]]'''
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**[[Brucellosis]], [[echinococcosis]], [[syphilis]]
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* Toxin
  
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* Toxins and drugs
 
** '''Alcohol'''
  
** '''Alcohol'''
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**Medications: [[isoniazid]], [[methotrexate]]
 
* Autoimmune/inflammatory
  
* Autoimmune/inflammatory
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** Autoimmune hepatitis (AIH)
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** [[Autoimmune hepatitis]] (AIH)
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** Primary biliary cirrhosis (PBC)
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** [[Primary biliary cirrhosis]] (PBC)
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**[[Primary sclerosing cholangitis]]
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**[[Celiac disease]]
 
* Metabolic
  
* Metabolic
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** '''NASH'''
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** '''[[NASH]]'''
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** Wilson's disease
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** [[Wilson disease]]
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** [[Hereditary hemochromatosis]]
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** Hemochromatosis
  
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** alpha-1 antitrypsin deficiency
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** [[α-1 antitrypsin deficiency]]
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*Other
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**Right-sided [[heart failure]]
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**[[Veno-occlusive disease]]
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**[[Hereditary hemorrhagic telangiectasia]]
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**[[Polycystic liver disease]]
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**[[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:
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* Decrease in platelets
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** Decrease in platelets
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* Increase in bilirubin
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** Increase in bilirubin
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* Decrease in albumin
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** Decrease in albumin
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* Increase in INR
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** Increase in INR
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*Investigations for possible causes of cirrhosis include:
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**Liver ultrasound
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**Hepatitis B and C serologies
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**Ferritin and transferrin saturation, for [[hereditary hemochromatosis]]
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**Autoimmune serologies
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***ANA and anti-smooth muscle antibodies, for [[PSC]] and [[AIH]]
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***Anti-mitochondrial antibodies and anti-parietal cell antibodies, for [[PBC]]
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***Consider anti-LKM-1, for [[PSC]]
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**Quantitative immunoglobulins, for elevated IgM in [[PBC]] or [[hypergammaglobulinemia]] in [[AIH]]
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**Consider serum ceruloplasmin, for [[Wilson disease]]
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**Consider α-1 antitripsyin levels, for deficiency
   
 
== Management ==
  
== Management ==
   
 
* Decompensated
  
* Decompensated
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** Rule out [[Spontaneous bacterial peritonitis]] with every episode
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** 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)
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=== Preventative Care ===
  
=== Preventative Care ===
   
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* Avoid raw oysters (high risk of ''Vibrio vulnificans'' infection in cirrhosis)
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* Avoid raw oysters (high risk of [[Vibrio vulnificus]] infection in cirrhosis)
   
 
== Prognosis ==
  
== Prognosis ==

Latest revision as of 22:23, 26 November 2021

Background

  • End-stage hepatic fibrosis with hepatic dysfunction

Epidemiology

  • 25% of Canadians have NAFLD

Etiology

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
  • 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

Prognosis

  • Median survival 1.6 years after admission for decompensated cirrhosis
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