1. DIAGNOSIS OF CIRRHOSIS
May 2018
UCI Internal Medicine

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

3. 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.

4. 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

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

6. 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

7. BONACINI DISCRIMINANT SCORE
Score >7 has likelihood ratio of 9.4 for cirrhosis
Platelets
ALT/AST
INR
> pt
> pt
< pt pt pt pt pt pt
> pt pt
< pt pt pt
< pt
High likelihood ratio

8. 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

9. 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

10. 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

11. 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

12. 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: /jama
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.