CIRRHOSIS Ahmed Salam Lectures Medical Student “TSU” WWW.GREATASSIMPLEMEDICINE.COM

Definition: G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Definition: Cirrhosis is a condition in which the liver does not function properly due to long-term damage . This damage is characterized by the replacement of normal liver tissue by scar tissue. Typically, the disease develops slowly over months or years. Early on, there are often no symptoms, As the disease worsens. WWW.GREATASSIMPLEMEDICINE.COM

Causes: G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Causes: Alcoholic liver disease (ALD). Alcoholic cirrhosis develops for 10–20% of individuals who drink heavily for a decade or more. Alcohol seems to injure the liver by blocking the normal metabolism of protein, fats, and carbohydrates. Non-alcoholic steatohepatitis (NASH). In NASH, fat builds up in the liver and eventually causes scar tissue. This type of hepatitis appears to be associated with obesity (40% of NASH patients) diabetes. Chronic hepatitis C , hepatitis B virus . Primary biliary cholangitis (also known as primary biliary cirrhosis). The bile ducts become damaged by an autoimmune process. WWW.GREATASSIMPLEMEDICINE.COM

G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Autoimmune hepatitis: This disease is caused by an attack of the liver by lymphocytes . Hereditary hemochromatosis: Usually presents with a family history of cirrhosis . Glycogen storage disease type IV Cystic fibrosis Hepatotoxic drugs or toxins WWW.GREATASSIMPLEMEDICINE.COM

Symptoms: G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Cirrhosis often has no signs or symptoms until liver damage is extensive. When signs and symptoms do occur, they may include: Fatigue Bleeding easily Bruising easily Itchy skin Yellow discoloration in the skin and eyes (jaundice) Fluid accumulation in your abdomen (ascites) Loss of appetite Nausea Swelling in your legs Weight loss Confusion, drowsiness and slurred speech (hepatic encephalopathy) Spiderlike blood vessels on your skin Redness in the palms of the hands WWW.GREATASSIMPLEMEDICINE.COM

Portal hypertension: G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Portal hypertension: Liver cirrhosis increases resistance to blood flow and leads to higher pressure in the portal venous system, resulting in portal hypertension. Effects of portal hypertension include: Splenomegaly (increase in size of the spleen) is found in 35% to 50% of patients. Esophageal varices result from collateral portal blood flow through vessels in the stomach and esophagus (a process called portacaval anastomosis). When these blood vessels become enlarged, they are called varices and are more likely to rupture .  Variceal rupture often leads to severe bleeding, which can be fatal. Caput medusa are dilated periumbilical collateral veins due to portal hypertension. Blood from the portal venous system may be shunted through the periumbilical veins and ultimately to the abdominal wall veins WWW.GREATASSIMPLEMEDICINE.COM

CIRRHOSIS APPERANCE G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT CIRRHOSIS APPERANCE WWW.GREATASSIMPLEMEDICINE.COM

CIRRHOSIS APPERANCE G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT CIRRHOSIS APPERANCE WWW.GREATASSIMPLEMEDICINE.COM

Pathophysiology: G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Pathophysiology: Cirrhosis is often preceded by hepatitis and fatty liver (steatosis), independent of the cause. If the cause is removed at this stage, the changes are fully reversible. The pathological hallmark of cirrhosis is the development of scar tissue that replaces normal parenchyma. This scar tissue blocks the portal flow of blood through the organ, raising the blood pressure and disturbing normal function. Recent research shows the pivotal role of the stellate cell, a cell type that normally stores vitamin A, in the development of cirrhosis. Damage to the hepatic parenchyma (due to inflammation) leads to activation of stellate cells, which increases fibrosis (through production of myofibroblasts) and obstructs hepatic blood flow. In addition, stellate cells secrete TGF-β1, which leads to a fibrotic response and proliferation of connective tissue. Furthermore, it secretes TIMP 1 and 2, naturally occurring inhibitors of matrix metalloproteinases, which prevents them from breaking down the fibrotic material in the extracellular matrix. WWW.GREATASSIMPLEMEDICINE.COM

G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT As this cascade of processes continues, fibrous tissue bands (septa) separate hepatocyte nodules, which eventually replace the entire liver architecture, leading to decreased blood flow throughout. The spleen becomes congested, which leads to hypersplenism and the spleen's retention of platelets, which are needed for normal blood clotting. Portal hypertension is responsible for the most severe complications of cirrhosis. WWW.GREATASSIMPLEMEDICINE.COM

Diagnosis: G.S.M MEDICAL LECTURES/ Cirrhosis Thrombocytopenia AHMED SALAM MD STUDENT Diagnosis: Thrombocytopenia Aminotransferases – AST and ALT are moderately elevated. Bilirubin – Levels normal when compensated but may elevate as cirrhosis progresses. Albumin – levels fall as the synthetic function of the liver declines with worsening cirrhosis WWW.GREATASSIMPLEMEDICINE.COM

G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Prothrombin time – increases, since the liver synthesizes clotting factors. Leukopenia and neutropenia – due to splenomegaly with splenic margination. Coagulation defects Imaging: Ultrasound is routinely used in the evaluation of cirrhosis. Endoscopy: Gastroscopy (endoscopic examination of the esophagus, stomach, and duodenum) is performed in patients with established cirrhosis to exclude the possibility of esophageal varices. WWW.GREATASSIMPLEMEDICINE.COM

G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT  liver biopsy: Accumlation of connective tissue(fibrosis) and show yelleow color due to fat( steatosis) WWW.GREATASSIMPLEMEDICINE.COM

Complications: G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Complications: High blood pressure in the veins that supply the liver (portal hypertension). Swelling in the legs and abdomen. Enlargement of the spleen (splenomegaly). Bleeding. Other complications: Infections. Malnutrition. Buildup of toxins in the brain (hepatic encephalopathy). WWW.GREATASSIMPLEMEDICINE.COM

Do not drink alcohol if you have cirrhosis. Eat a healthy diet. G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Jaundice. Bone disease. Increased risk of liver cancer. Acute-on-chronic liver failure. Prevention: Do not drink alcohol if you have cirrhosis. Eat a healthy diet. Maintain a healthy weight. WWW.GREATASSIMPLEMEDICINE.COM

Treatment: G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Treatment: Treatment for cirrhosis depends on the cause and extent of your liver damage. The goals of treatment are to slow the progression of scar tissue in the liver and to prevent or treat symptoms and complications of cirrhosis. You may need to be hospitalized if you have severe liver damage. Treatment for the underlying cause of cirrhosis: Treatment for alcohol dependency Weight loss. Medications to control hepatitis. WWW.GREATASSIMPLEMEDICINE.COM

G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Treatment for complications of cirrhosis: Excess fluid in your body. Portal hypertension.  Infections. Hepatic encephalopathy. WWW.GREATASSIMPLEMEDICINE.COM

G.S.M MEDICAL LECTURES/ Cirrhosis AHMED SALAM MD STUDENT Liver transplantation: In advanced cases of cirrhosis, when the liver ceases to function, a liver transplant may be the only treatment option. People usually need to consider this option when they develop symptoms from cirrhosis, such as jaundice, significant fluid retention (ascites), bleeding varices, hepatic encephalopathy, kidney dysfunction, or liver cancer. A liver transplant replaces your liver with a healthy liver from a deceased donor or with part of a liver from a living donor. Cirrhosis is the most common reason for a liver transplant. WWW.GREATASSIMPLEMEDICINE.COM