Cirrhosis

Cirrhosis

• Path: 
  • The pathologic end stage to any chronic liver disease
  • Results in hepatic fibrosis and loss of hepatic architecture and function

• ---

  Etiology:

Calculation Scores

• MELD score:
  • Model for End-Stage Liver Disease- degree of medical urgency (score >15 & complications); higher the bilirubin, higher INR, higher the priority

• ---

  Child-Pugh class:
  • used to determine need for prophylaxis with medication vs band ligation in varices in cirrhosis pts

Esophageal Varices

• PPX Treatment:
  • Nonselective beta blocker, or
    
  • endoscopic prophylaxis using endoscopic variceal ligation (EVL).

• ---

  Correct Coagulopathy from variceal bleeding:
  • Fresh frozen plasma, PCC (Kcentra ), and recombinant Factor VII

• ---

  TIPS (Transjugular intrahepatic portosystemic shunt- reduces elevated portal pressure):
  • Patients with uncontrolled bleeding and those with early rebreeding

Portal Hypertensive Gastropathy

• Caused:
  • portal hypertension and results in congestion and hyperemia of the stomach (stomach congestion)
    

• ---

  Dx:
  • EGD and tx same as varices

Ascites

• Purpose of Treatment:
  • Makes the patient feel better with less discomfort (pain/sob) and reduces energy expenditure
    
  • Protects against Spontaneous bacterial peritonitis
    
  • Reduces risk of abdominal wall hernias, diaphragmatic rupture, and abdominal wall cellulitis

• ---

  Chylous Ascites
  • has a triglyceride content greater than 200 mg/dL (2.26 mmol/L) and usually greater than 1000 mg/dL

• ---

  Treatment:
  • Abstinence from alcohol
  • Restrict dietary Na 2000 mg/day
  • Treat underlying liver disease
  • Diuretic therapy
  • D/c meds that decrease renal perfusion (ACE, ARB, NSAID)
  • Paracentesis for large-volume ascites removal.

• ---

  Can be administered if over 5 liters of ascites fluid is removed:
  • Albumin (25 grams of 25% solution) can be administered to help hemodynamics and prevent hypovolemia.

• ---

  Ascites fluid testing:
  • Opalescent or milky fluid may be due to high triglyceride
  • Brown fluid may be seen if bilirubin is really high or bowel perforation
  • Bloody fluid-traumatic tap; also hepatocellular cancer
  •  
  • Cell count and differential: consider antibiotic treatment if >250
  • Culture and gram stain
  • Total Protein: exudate if TP >2.5-3, transudate if <2.5

Spontaneous Bacterial Peritonitis (SBP)

• Def:
  • Infection of Ascitic Fluid in the absences of an intra-abdominal surgically treatable source

• ---

  Presentation:
  • Pts with cirrhosis and fever, abdominal pain, and altered mental status

• ---

  Diagnosed:
  • Positive fluid bacterial culture
  • Fluid absolute PMN count ≥250 cells/microL

• ---

  Treatment:
  • Empiric, broad-spectrum antibiotics immediately after peritoneal fluid is obtained.
  • SOFA Score <7 
    • Typically 3rd gen Cephalosporin Ceftriaxone or Cefotaxime
  • SOFA Score >7
    • Carbapenem

• ---

  Major cause of death:
  • Renal failure – occurs in 30-40%
    
  • IV 25g of 25% albumin admin within six hrs of diagnosis, also given if Cr >1

Hepatic Encephalopathy

• Severity:
  • Grade I: Changes in behavior, mild confusion, slurred speech, disordered sleep
    
  • Grade II: Lethargy, moderate confusion
    
  • Grade III: Marked confusion (stupor), incoherent speech, sleeping but arousable
    
  • Grade IV: Coma, unresponsive to pain

• ---

  Severity Treatments:
  • Grade I: Tx outpt with increase in meds – lactulose given
    
  • Grade II: may be managed outpt if caregivers are reliable to bring pat back for worsening and pt can reliably take meds.
    
  • *Pts with more severe HE (grades III – IV) require hospital admission for tx

Hepatocellular Carcinoma

• Risk Factors (higher risk):
  • hepatitis B
  • hepatitis C
  • nonalcoholic steatohepatitis
  • hemochromatosis

• ---

  Suspicion:
  • Decompensation in a patient with prior compensated cirrhosis should raise clinical suspicion, often asymptomatic until decompensation occurs.

• ---

  Presentation:
  • pain
  • early satiety
  • obstructive jaundice
  • palpable mass.

• ---

  Labs/Imaging:
  • AFP and Ultrasound done every six months
    
  • (AFP will be elevated)
  • Tumor > 1cm: CT with contrast or MRI with and without contrast

NAFLD

• Presentation:
  • Most asymptomatic
    
  • Fatigue, malaise, vague RUQ discomfort

• ---

  Physical Exam:
  • May have hepatomegaly

• ---

  Labs:
  • Incidental finding: elev ALT and AST 
    
  • mild to mod increase in ALT and AST; Ratio AST:ALT <1 (Unlike alcoholic fatty liver disease in which ratio AST/ALT typically >2)

• ---

  Imaging: 
  • Incidental finding
  • Demonstration of hepatic steatosis by imaging or biopsy
    
  • *must r/o other disorders

• ---

  Treatment:
  • ETOH- Abstain
  • Hepatitis A and B vaccine
  • Modify risks for CV disease
  • Weight loss
  • Vit E 800 IU/day-For patients with bx proven NASH and fibrosis stage ≥2 who do not have DM
  • Omega-3-fatty acids
  • Atorvastatin-benefit combined with vit E and C
  • Monitor ALT and AST q6mos
  • Can monitor elastography to estimate fibrosis