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Cirrhosis (End Stage Liver Disease)
- Cirrhosis is a fibrosis or scaring of the liver. Normally functioning liver tissue is replaced with non functioning scar tissue over time.
- Typically an insidious onset over months or years
- Portal hypertension and decreased liver function cause most of the symptoms of cirrhosis
Risk Factors/Causes
- Chronic hepatitis
- Chronic alcohol abuse
- Non-alchohlic steatohepatitis
- The porgesssion of non alcoholic fatty liver disease
- Drug toxicity
- Age > 55
- Diabetes
- Obesity
Clinical Presentation & Physical Exam Findings
- Weakness and fatigue
- Nausea and anorexia
- Symptoms associated with decreased liver function
- There is an increase in female sex hormones and a decrease in male sex hormones related to poor liver function causing
- Palmar erythema
- Gynecomastia
- Infertility
- Erectile dysfunction
- Loss of sex drive
- Spider angioma – vascular lesions
- Ascites – Fluid build up in the abdomen
- Elevated bilirubin
- Jaundice
- Pruritis
- Dark colored urine
- Decrease in clotting factors
- Easy brusibilty
- Increased bleeding times
- Hepatic encephalopathy
- Mental status changes caused by increasing levels of amonia and other toxins typcially cleared from the blood by the liver
- Forgetfullness
- Difficulty concentrating
- Asterixis – A tremor or flapping of the hand when the wrist is extended
- Delirium
- Psycocissis
- Coma
- Mental status changes caused by increasing levels of amonia and other toxins typcially cleared from the blood by the liver
- There is an increase in female sex hormones and a decrease in male sex hormones related to poor liver function causing
- Symptoms associated with portal hypertension
- Splenomegaly
- GI bleeding
- Esophageal varices
- Gastric varices
- Rectal varices
- Caput Medusa
- Peripheral edema
Labs and Studies
- Anemia
- Folate deficiency secondary to alcoholism may lead to a macrocytic anemia
- Clotting issues may lead to thrombocytopenia
- GI bleeds may lead to anemia
- Increased prothrombin time
- Elevated aspartate transaminase (AST) and alanine transaminase (ALT)
- Elevated bilirubin
- Low serum albumin
- Hepatitis serology tests to determine causative agent
- Ultrasound
- Determine size of liver
- Check hepatic blood flow
- Determine the size of the spleen
- CT/MRI with contrast for hepatic nodules
- Liver biopsy
Treatment
- Cirrhosis can not be reversed. Treatment and behavior modification are used to relieve symptoms and slow the progression.
- Stop drinking alcohol
- Healthy diet and exercise
- Strict diabetes control
- Antivirals to treat hepatitis infection
- For edema and ascites restrict fluids and sodium. Dieresis if necessary.
- For anemia – Folate 1 mg daily, iron and possible transfusion
- For increase bleeding times – Fresh frozen plasma if necessary
- Liver transplant
Hepatocellular Carcinoma
- 80% of cases are associated with cirrhosis
Risk Factors
- Chronic hepatitis
- Chronic alcohol abuse
- Non-alchohlic steatohepatitis
- The porgesssion of non alcoholic fatty liver disease
- Drug toxicity
- Age > 55
- Diabetes
- Obesity
Clinical Presentation
- Deterioration of a patient with cirrhosis who had been stable
- Sudden ascites
- Cachexia – muscle atrophy
- Weight loss
Labs, Studies and Physical Exam Findings
- Elevated WBC as opposed to often decreased WBC in cirrhosis
- Elevated alkaline phosphatase
- Elevated alpha fetoprotein
- CT/MRI with contrast
- Ultrasound
- Liver biopsy
Treatment
- Prevention
- Hep vaccinations
- Monitor patient with cirrhosis or chronic hepatitis with alpha fetoprotein and U/S
- Pain management as expansion of the liver capsule can be very painful
- Surgical removal of the carcinoma. Around 10-20% of carcinomas have the potential to be fully removed.
- Liver transplant