DIAGNOSIS OF CIRRHOSIS May 2018 UCI Internal Medicine

OBJECTIVES: Discuss when a diagnosis of cirrhosis should be suspected Discuss physical exam findings common to cirrhosis Overview common causes of cirrhosis

Case 57 year old male presenting to the ED with yellowing of his skin. He has also noted swelling of his abdomen and ankle. He is a former IV drug user and has drank a 6 pack of beer for the last 35 years. On exam, he is an obese, jaundiced male with icteric sclera. His abdomen is distended with a fluid wave and he has pitting edema to his knees bilaterally. What are possible underlying diagnosis for this patient? What are the possible causes of his disease? What other physical exam findings might be found? Ask listeners to keep this in mind while going through the presentation, will return to this case later.

WHEN TO SUSPECT CIRRHOSIS Stigmata of chronic liver disease on physical exam (2/2 portal hypertension) Ascites (LR 7.2) Spider angiomata (LR 4.3) Skin/extremities: jaundice, palmar erythema, gynecomastia, Muehrcke nails (horizontal white bands separated by normal color), Terry nails (prox 2/3 of nail is white, distal 1/3 is red) Abdomen: caput medusa, hepatosplenomegaly, Cruveilhier- Baumgarten murmur (hum auscultated over abdomen) GU: testicular atrophy LR = likelihood ratio Images of these are on next slide

PHYSICAL EXAM FINDINGS Spider nevi Sodie T. Valesquex, MD, Alcoholic Liver Disease Palmar erythema Caput medusae Muehrcke Nails Terry Nails wikipedia up to date

WHEN TO SUSPECT CIRRHOSIS, CONT Imaging findings consistent with cirrhosis Ultrasound Surface nodularity & increased echogenicity If with doppler, can provide info about portal flow Lab abnormalities Thrombocytopenia, ALT/AST, INR derangement Bonacini discriminant score Biopsy is not necessary. Diagnosis is based on clinic picture of history, physical, imaging, and labs

BONACINI DISCRIMINANT SCORE Score >7 has likelihood ratio of 9.4 for cirrhosis Platelets ALT/AST INR >340 - 0 pt >1.7 - 0 pt <1.1 - 0 pt 280-339 - 1 pt 1.2-1.7 - 1 pt 1.1-1.4 - 1 pt 220-279 - 2 pt 0.6-1.19 - 2 pt >1.4 - 2 pt 160-219 - 3 pt <0.6 - 3 pt 100-159 - 4 pt 40-99 - 5 pt <40 - 6 pt High likelihood ratio

CAUSES OF LIVER CIRRHOSIS More common: Alcohol Non-alcoholic fatty liver Chronic viral hepatitis (B & C) Hemochromatosis Less common: Autoimmune hepatitis, primary & secondary biliary cirrhosis, Wilson, A1AT, Right heart failure, etc

MORBIDITY/MORTALITY (PER CDC) 3.9 million (1.6%) adults in US with diagnosed cirrhosis >40,000 deaths per year MELD-Na - Prognostic model using lab values Typically to prioritize for liver transplant (candidates once >15) Provides 90 day mortality estimate Incorporates TBili, INR, Creatinine, Sodium Child-Turcotte-Pugh Score Incorporates clinical + lab data: ascites, encephalopathy, TBili, PT/INR, albumin

Case 57 year old male presenting to the ED with yellowing of his skin. He has also noted swelling of his abdomen and ankle. He is a former IV drug user and has drank a 6 pack of beer for the last 35 years. On exam, he is an obese, jaundiced male with icteric sclera. His abdomen is distended with a fluid wave and he has pitting edema to his knees bilaterally. What is the likely underlying diagnosis for this patient? What are the possible causes of his disease? What other physical exam findings might be found? Cirrhosis of liver Alcohol, hepatitis C, NASH (others less likely like hemochromatosis Palmar erythema, caput medusa, spider nevi/angiomata

Summary Cirrhosis is a diagnosis which incorporates history, physical exam, laboratory findings, and imaging There are many causes of cirrhosis, but alcoholic, NASH, and chronic viral hepatitis are the most common Cirrhosis is relatively common and the MELD-Na score can help estimate mortality

RESOURCES Up-to-date Udell JA, Wang CS, Tinmouth J, et al. Does This Patient With Liver Disease Have Cirrhosis?. JAMA.2012;307(8):832–842. doi:10.1001/jama.2012.186 https://www.cdc.gov/nchs/fastats/liver-disease.htm Sharma, Barjesh Chander, et al. "A randomized, double-blind, controlled trial comparing rifaximin plus lactulose with lactulose alone in treatment of overt hepatic encephalopathy." The American journal of gastroenterology 108.9 (2013): 1458.