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.
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.
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.
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.
These are performed to assess the severity of liver disease, identify the aetiology and screen for complications.
■ 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.
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.
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.
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.
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%.
1. Ethics and communication
2. Infectious diseases
3. 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
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER DISEASE IN PREGNANCY
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS
5. Haematological disease
Assessment and treatment of suspected neutropenic sepsis
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
6. Malignant disease
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
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
9. Renal disease
INVESTIGATION OF RENAL DISEASE
URINARY TRACT INFECTION
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
10. Cardiovascular disease
COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
ISCHAEMIC HEART DISEASE
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
ARTERIAL AND VENOUS DISEASE
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS
11. Respiratory disease
12. Intensive care medicine
13. Drug therapy, poisoning, and alcohol misuse
14. 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
15. Diabetes mellitus and other disorders of metabolism
16. The special senses
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
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES