Cirrhosis

Cirrhosis

= chronic liver disease that is characterized by scarring tissue and nodules.
Injury (NAFLD, viral Hep B/C, alcoholic) -> Inflammation -> Necrosis (death) liver cells -> Fibrosis + Nodule formation.
Necrosis -> release of cytokines -> activation of stellate cells -> Fibrosis, deposition of connective tissue such as collagen in Disse space.
Nodules are basically liver tissue regenerating and trying to repair.

Histology, characteristic features are regenerating nodules separated by fibrous septa. There are two types of cirrhosis based on histology;
-        Micronodular <3 mm -> Alcohol
-        Macronodular -> Viral

Symptoms ->  Liver diseases
-        Asymptomatic
-        Nonspecific symptoms
-        Jaundice
-        Hypochondrial pain
-        Ascites
-        Edema
-        Pruritus (= itching)
-        Gynaecomastia, loss of libido, amenorrhoea.
-        Spider naevi
-        Portal hypertension -> splenomegaly, oesophageal varices, hepatic encephalopathy, hepatorenal syndrome.

Investigation

-        Liver function; low serum albumin, prothrombin time is prolonged.
-        Liver biochemistry; slight elevation in the serum Alkaline phosphatase and serum aminotransferases.
-        Serum electrolytes; low sodium due to defect in water clearance.
-        Serum creatinine; elevated concentration -> worse prognosis.
-        Serum α-fetoprotein >200 ng/mL -> Hepatocellular carcinoma.

Type

-        Viral markers -> hepatitis
-        Serum autoantibodies -> Autoimmune hepatitis, PSC
-        Serum immunoglobulins -> Autoimmune hepatitis.
-        Iron indices and ferritin -> hereditary haemochromatosis
-        Copper, caeruloplasmin -> Wilsons
-        α1-antitrypsin -> genetic disorder

!! Serum copper and serum α1-antitrypsin should always be measured in young cirrhotics.

Imaging

Ultrasound: changes in size and shape  of liver is seen along with abnormality in the vascular architecture. Elastography is being used to avoid biopsy.
CT-scan -> heptaosplenomegaly, hepatocellular carcinoma
Endoscopy -> detection and treatment of varices and portal hypertensive gastropathy.
MRI -> diagnosis of maligant and benign tumors.
MR angiograpy -> vascular anatomy,
MR cholangiography -> biliary tree.

Liver biopsy
Liver biopsy is the golden standard of diagnosis of cirrhosis, nowadays avoided thanks to elastrography. Usually necessary to confirm the type and severity. Sampling errors possible due to nodules. Important to take adequate amount of samples to avoid putting your patient through it again.

Management

Treatment of the underlying disease!! Reduce salt intake, avoid NSAIDs/Aspirin, avoid alcohol-> viral hep and alcoholic hep patients.
6-monthly ultrasound to detect early development of hepatocellular carcinoma. Liver transplantation

Course and prognosis

Variable, depends on factors. Overall 5-year survival rate is 50%. Use scoring system of Modified Child-Pugh classification for survival rate calculation.