cirrhosis of the liver
TRANSCRIPT
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CIRRHOSIS OF LIVER
Avaneesh Jakkoju, M.D.
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Definition
“ (cirrhosis is defined as) the pathologic features consist of the development of fibrosis to the point that there is architectural distortion with the formation of regenerative nodules.”
Harrison’s principles of internal medicine, 17th edition
“widespread disruption of normal liver structure by fibrosis and the formation of regenerative nodules that is caused by any of various chronic progressive conditions affecting the liver. “
Miriam Webster dictionary
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Global prevalence of Cirrhosis
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Causes of Cirrhosis
Chronic viral hepatitis Alcoholic liver disease Nonalcoholic steatohepatitis Billiary cirrhosis
Primary biliary cirrhosis Primary sclerosis cholangitis Autoimmune cholangiopathy
Cardiac cirrhosis Autoimmune hepatitis Inherited metabolic liver disease
Hemochromatosis Wilson’s disease α1 Antitrypsin deficiency Cystic fibrosis
Medications (Isoniazide, Methotrexate) Cryptogenic/idiopathic cirrhosis Hereditary hemorrhagic telengectasia
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Morphologic classification
Micronodular cirrhosis Macronodular cirrhosis Mixed
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Clinical features
Anorexia Weight loss Weakness Fatigue Muscle cramps Easy bruising Amenorrhea/
Oligomenorrhea Decreased libido
Jaundice Dark/cola colored urine Pruritis Hematemesis Melena Hematochezia Abdominal distention Lower extremity
edema Confusion and sleep
disturbance
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Extra hepatic manifestations… Depending on the etiology of cirrhosis
patients have different extra hepatic manifestations such as Cryoglobulinemia from Hep C Diabetes mellitus and arthropathy from
hemochromatosis Hemolytic anemia or thyroiditis in
autoimmune hepatitis.
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Physical examination
Decreased blood pressure Hepatomegaly Splenomegaly Gynecomastia Loss of chest or axillary hair Testicular atrophy Cruveilhier-Baumgarten murmur
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Jaundice
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Spider angiomata
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Palmar erythema
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Dupuytren’s contracture
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Caput medusa
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Muehrcke nails
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Terry nails
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Clubbing
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Signs of advanced disease
Fetor hepaticus Fetor hepaticus refers to a sweet, pungent
smell to the breath of a patient with cirrhosis. It is caused by increased concentrations of dimethyl sulfide, the presence of which suggests underlying severe portal-systemic shunting.
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Acites
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Asterexis
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Laboratory findings
Aminotransferases AST and ALT are moderately elevated in cirrhosis.
Normal levels should not rule out the diagnosis. Alakaline phosphotase Gamma glutamyl transpeptidase Bilirubin Albumin Prothrombin time Hyponatremia Thrombocytopenia Anemia
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Imaging
Ultrasound First choice for initial evaluation High resolution USG has a sensitivity of 91% and
specificity of 94% CT scan
Not superior to USG Higher cost, radiation and contrast exposure
MRI ? Accurate diagnosis and correlation with severity Useful for measuring liver iron stores MRA is more sensitive than USG for portal vein
thrombosis Nuclear studies
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Liver biopsy
Gold standard is examination of explanted liver
Percutaneous biopsy Image guided biopsy
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Determining the cause
Important Can be done in 85 to 90% cases When found treatment should be aimed
at that particular cause Also gives information regarding
prognosis If initial evaluation with history and labs
is inconclusive look for rarer causes of cirrhosis
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Management strategies
Detailed history Thorough physical examination Labs Imaging Biopsy if needed Determine the cause Appropriate referrals where needed Explain diagnosis and prognosis Life style modifications; no EtOH, no hepatotoxic
drugs Follow response to treatment If everything fails, consider transplantation on case
by case basis
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“I tried to pay attention, but attention paid me.”
-Lil’ WayneShe will; The carter IV
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Thank you