Cirrhosis | Clinical Medicine

Introduction

This tutorial provides a comprehensive overview of cirrhosis, including its pathophysiology, causes, complications, diagnostics, and treatment options. Understanding cirrhosis is crucial for anyone studying clinical medicine, as it is a significant condition with serious implications for liver function and patient health.

Chapter 1: Understanding Cirrhosis

• Definition: Cirrhosis is the irreversible fibrosis (scarring) of the liver that leads to decreased liver function and can cause portal hypertension.
• Pathophysiology:
  • Chronic liver injury leads to damage and inflammation, resulting in fibrosis and nodular regeneration.
  • Key liver cells involved:
    • Hepatocytes: Functional liver cells.
    • Stellate cells: Involved in the formation of fibrous tissue after injury.

Chapter 2: Causes of Cirrhosis

• Direct Parenchymal Damage:

  • Alcohol-related liver disease: Most common cause in chronic liver disease.
  • Autoimmune hepatitis: Recognized by specific antibodies; treated with steroids.
  • Viral infections: Hepatitis B and C viruses cause direct liver cell injury.
  • Metabolic diseases:
    • Hemochromatosis: Iron overload in the liver.
    • Wilson's disease: Copper accumulation.
    • Non-alcoholic fatty liver disease: Associated with obesity and metabolic syndrome.

• Indirect Injury:

  • Vascular diseases: Right heart failure and Budd-Chiari syndrome can lead to hepatic congestion.

• Biliary Tract Diseases: Chronic inflammation can cause bile backflow and liver damage (e.g., primary biliary cholangitis).

Chapter 3: Complications of Cirrhosis

• Portal Hypertension:

  • Increased pressure in the portal vein due to fibrosis leads to complications like esophageal varices and ascites.

• Decreased Liver Function:

  • Symptoms include jaundice (due to bilirubin accumulation), coagulopathy (due to decreased clotting factors), and hepatic encephalopathy (due to ammonia build-up).

• Hepatocellular Carcinoma: Chronic inflammation can lead to liver cancer; monitor with ultrasounds and alpha-fetoprotein levels.

Chapter 4: Diagnostics of Cirrhosis

• Laboratory Tests:

  • CBC, LFTs (look for elevated bilirubin and decreased albumin), PT/INR (elevated indicates coagulopathy).

• Imaging:

  • Abdominal ultrasound with elastography: Assess liver stiffness for fibrosis.

• Liver Biopsy: Definitive diagnosis to show nodular fibrosis.

Chapter 5: Treatment Options

• Managing Ascites:

  • Sodium restriction and diuretics (spironolactone and furosemide).
  • Large volume paracentesis with albumin replacement if more than 5 liters are removed.

• Treating Spontaneous Bacterial Peritonitis (SBP):

  • Antibiotics such as cefotaxime.

• Hepatic Encephalopathy:

  • Lactulose to reduce ammonia levels.

• Hepatorenal Syndrome Management:

  • Use vasoconstrictors (e.g., octreotide) and volume expansion with albumin.

• Variceal Bleeding:

  • Octreotide and prophylactic antibiotics; endoscopic ligation as needed.

• Monitoring for Liver Cancer:

  • Regular ultrasound and alpha-fetoprotein checks.

Conclusion

Cirrhosis is a complex condition that requires a multi-faceted approach for management and treatment. Recognizing the causes, complications, and appropriate diagnostic methods is essential for effective patient care. Next steps involve continuous monitoring and supportive treatment tailored to individual patient needs, with an ultimate consideration for liver transplantation as the disease progresses.