1. Assist. Prof. Mona Arafa Tropical Medicine Department
Liver Cirrhosis
Assist. Prof. Mona Arafa
Tropical Medicine Department

2. Objectives Understand the basic mechanisms of Liver cirrhosis
Recognize the classic presentations of Liver cirrhosis and its complications
Get an idea about the management of these complications

4. Loss of normal function
Definition:
Diffuse disorder of liver characterised by;
Complete loss of normal architecture,
Replaced by extensive fibrosis with,
Regenerating parenchymal nodules. ▼
Loss of normal function

5. Pathophysiology ►Slow, insidious, progressive, chronic
►Fibrous bands replace normal liver structure
► Cell degeneration occurs
► Liver attempts to regenerate cells but cells are abnormal and disorganized
► Causes abnormal blood and lymph flow
► Results in more fibrous tissue formation

6. Normal Liver

7. Cirrhosis

8. Normal Liver HistologyCV PT

9. Cirrhosis
Fibrosis
Regenerating Nodule

10. Classification of Cirrhosis
◘ WHO divided cirrhosis into 3 categories based on morphological characteristics of the hepatic nodules
Micronodular
Macronodular
Mixed 10

11. Causes of Cirrhosis Chronic viral hepatitis(HCV, HBV±HDV)
Metabolic: hemochromatosis, Wilson dis, alfa-1-antitrypsin, NASH
Prolonged cholestasis (PBC, PSC)
Autoimmune hepatitis
Hepatic venous outflow obstruction (VOD, BCS, Constrictive pericarditis)
Drugs and toxins
Alcohol

12. Clinical Presentation
Stigmata of chronic liver disease.
Abnormal LFTs and CBC.
Radiographic abnormalities.
Complication of cirrhosis.
Cirrhotic appearance of the liver at laparotomy or laparoscopy.

13. Clinical Features *Fatigue, anorexia, malaise.
*Weight loss & muscle wasting.
*Jaundice & dark urine.
*Parotid enlargement & diarrhea.
*Anemia, leucopenia, thrombocytopenia.
*Bleeding gum, epistaxis, ecchymosis.
*Spider angioma, palmar erythema, white nails, dilated veins.

14. Clinical Features Cont.
*Gynecomastia, change in body hair patterns.
*Amenorrhea, loss of libido, testicular atrophy, impotence.
*Swelling of LL and abdomen.
*Dyspnea & hypoxia.
*Increased susceptibility to infections.

15. “White Nails”
Seen in cirrhosis

16. Palmar Erythema

17. Clinical Features of Cirrhosis

18. Prominent abdominal veins.

19. Complications Portal hypertension Ascites Varices Coagulation defects
Hepatic encephalopathy
Hepatocellular carcinoma
Hepatorenal syndrome

20. Diagnosis of cirrhosis
Physical examination
*Stigmata of chronic liver disease
*Features of portal hypertension
*Hepatic encephalopathy
Laboratory evaluation
*Tests for hepatocellular necrosis
*Tests for cholestasis
*Tests for synthetic function
*Special tests for the cause
*Screening test for HCC; AFP

21. Diagnosis of cirrhosis
Imaging modalities
*Abdominal ultrasound.
*Computed tomography (CT).
*Magnetic resonance imaging (MRI).
*Fibroscan
Esophagogastroduodenoscopy (EGD).
Liver Biopsy.

22. Prognosis *Depends on the development of cirrhotic complication
*Assessed by Child-Turcotte-Pugh score
*Model for End-stage Liver Disease (MELD)
Based on serum bilirubin, creatinine, and INR
Determine optimal timing for liver transplantation

23. Child-Pugh score Class A: 5-6 Class B: 7-9 Class C: 10-15 score 1 2 3
Albumin.
>3.5
<2.8
Bilrubin
<2
2-3
>3
Ascites
Absent
Mild-Moderate
Severe/
Refractory HE
Mild (I-II)
Severe (III-IV)
PT prolongation
<4 sec.
(<1.7)
4-6 sec. ( )
>6 sec.
(>2.3)
Class A: Class B: Class C: 10-15

24. Management Specific treatment *Antiviral in HBV-cirrhosis
*Corticosteroids in AIH
*Phlebotomy in hemochromatosis
Treatment of complications
Screening for HCC
Liver transplantation

25. Portal hypertension
Definition : Increase in hepatic sinusoidal pressure to ≥ 6mm Hg. N.B : Portal pressure must be at least 10mm Hg for gastroesophegeal varices to develop and at least 12mm Hg for varicees to bleed.

26. Portal hypertension is classified as : prehepatic , hepatic and post hepatic. Prehpatic causes include : *Splenic vien thrombosis *Portal vein thrombosis (associated with hpercoagulable states and with malignancy )

27. Intrahepatic causes : Presinusoidal : eg
Intrahepatic causes : Presinusoidal : eg. Schistosomiasis Sinusoidal : eg. Cirrhosis Post sinusoidal : eg. VOD

28. Post hepatic causes :. Chronic right sided heart failure. TR
Post hepatic causes : *Chronic right sided heart failure *TR *Obstructing lesions of hepatic viens and I.V.C (Budd-chiari syndrome )

29. Management of complications Varices
May be esophageal, gastric, colo-rectal
Diagnosis
*History : Hematemesis, melena
*Physical examination
*Ultrasound abdomen
*Endoscopy

30. Esophageal Varices

31. Management of complications Varices
*ABC
*Two IV Lines
*Blood group
*Resuscitation (fluid, blood, FFP)
*IV vasoconstrictors (Octreotide)
*Endoscopic therapy (EST, EBL)
*Shunting (surgical, TIPS)

32. EST & EBL

33. Management of complications Varices
Prevention
*Endoscopy for every cirrhotic patient at diagnosis and periodically
*Treat underlying disease
*Beta blockers
*Endoscopic Band Ligation (EBL)

34. Ascites

36. Management of complications Ascites
Diagnosis
*Bulging flanks, shifting dullness, fluid wave
*Ultrasound
*Ascites taping (SAAG, SBP)
Treatment
*Salt restriction (<2gm/d)
*Diuretics (spironolactone, loop diuretics)
*Paracentesis

37. Paracentesis

38. Hepatic encephalopathy
Neuropsychiatric abnormalities secondary to liver disease

39. Pathogenesis of Hepatic Encephalopathy
BRAIN
LIVER
Toxic N2 metabolites
From Intestines
Porta systemic
shunts

43. Management of complications Hepatic encephalopathy
Treatment
*Identify and treat precipitating factor
*Low protein diet
*L-ornithine L-aspartate
*Antibiotics
(Neomycin, metronidazole, rifaximin)
*Lactulose
*Enemas
*Transplantation

45. Thank You