CIRRHOSIS - Clinical features, Differential diagnosis, Prophylaxis

Cirrhosis results from necrosis of liver cells followed by fibrosis and nodule formation. The end result is impairment of liver cell function and gross distor-tion of the liver architecture, leading to portal hypertension.

Aetiology

The causes of cirrhosis are shown in Table 4.1. Alcohol is the most common cause in the Western world, but hepatitis B and C are the most common causes world-wide.

Pathology

Histologically, 1wo types are described:

■ Micronodular cirrhosis: uniform, small nodules up to 3 mm in diameter. This type is often caused by ongoing alcohol damage or biliary tract disease.

■ Macronodular cirrhosis: nodules of variable size and normal acini may be seen within large nodules. This type is often seen following chronic viral hepatitis.

There is also a mixed picture, with both small and large nodules.

Clinical features

These are secondary to portal hypertension and liver cell failure (Fig. 4.1). Cirrhosis with the complications of encephalopathy, ascites or variceal haemorrhage is designated decompensated cirrhosis. Cirrhosis without any of these complications is termed compensated cirrhosis.

Investigations

These are performed to assess the severity of liver disease, identify the aetiology and screen for complications.

Severity

■ Liver biochemistry may be normal. In most cases there is at least a slight elevation of the serum alkaline phosphatase and aminotransferases.

■ Full blood count shows thrombocytopenia in most patients at diagnosis with leukopenia and anaemia developing later.

■ Liver function. Prothrombin time and serum albumin are the best indica-tors of liver function (p. 140).

■ Serum electrolytes. A low sodium concentration indicates severe liver disease secondary to either impaired free water clearance or excess diuretic therapy. An elevated serum creatinine is associated with a worse prognosis.

■ Serum a-fetoprotein (AFP). This is usually undetectable after fetal life, but raised levels may occur in chronic liver disease. A level greater than 200 ng/mL is strongly suggestive of the presence of an HCC, developing as a complication of cirrhosis.

Aetiology

Cirrhosis develops in response to chronic liver injury from any cause which is often apparent from the history combined with laboratory investigations (Table 4.1). A liver biopsy is performed to confirm the severity and type of liver disease.

Further investigations

Oesophageal varices are sought with endoscopy and primary prophylaxis (p. 165) to reduce bleeding offered to those with varices. An US is useful for detection of HCC, and to assess the patency of the portal and hepatic veins (p. 177). A dual energy X-ray absorptiometry (DXA) scan is performed for osteoporosis.

Management

Cirrhosis is irreversible and frequently progresses. Management is that of the complications seen in decompensated cirrhosis as they arise. Correcting the underlying cause, e.g. venesection for haemochromatosis, abstinence from alcohol for alcoholic cirrhosis, may halt the progression of liver disease. Screening for HCC (measurement of serum AFP and US every 6 months) is performed to identify tumours at an early stage. Liver transplantation should be considered in patients with end-stage cirrhosis. Patients should also be offered influenza immunization.

Prognosis

This is variable and depends on the aetiology and presence of complications. The severity and prognosis of liver disease can be graded according to the modified Child-Pugh classification (dependent on five variables: encepha-lopathy, ascites, prothrombin time, serum bilirubin and albumin) or the MELD score (modification of end-stage liver disease dependent on serum bilirubin and creatinine, and the international normalized ratio [INR]). Overall, the 5-year survival rate is approximately 50%.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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