Cirrhosis
- Late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture and the formation of regenerative nodules
Causes
- Alcohol
- Non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH)
- Chronic HBV, HCV, HDV infections
- Autoimmune hepatitis
- Drug induced (e.g., methotrexate)
- Metabolic diseases: haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency
- Biliary tract diseases
- Vascular disorder: Budd-Chiari syndrome, right heart failure, constrictive pericarditis
Signs and Symptoms
- Liver failure: jaundice, spider naevi, palmar erythema, Dupuytren's contracture, leukonychia, parotid gland enlargement, gynaecomastia, testicular atrophy, coagulopathy, asterixis, encephalopathy
- Signs of portal hypertension: oesophageal varices, epigastric venous hum, caput medusae, ascites, splenomegaly
- Shrunken, nodular liver
Investigation
- LFT
- US abdomen: small nodular liver with increased echogenicity with irregular appearing areas
- Fibroscan
- Liver biopsy
- Consider AFP – risk stratify for hepatocellular carcinoma (HCC)
- Work up the cause of cirrhosis
Management
- Symptomatic treatment
- Prevention and treatment of complications: spontaneous bacterial peritonitis, hepatic encephalopathy
- Liver transplant (Child-Pugh classes B and C)
Complications of Cirrhosis
Hepatic Encephalopathy
- Neuropsychiatric abnormalities in patients with liver dysfunction and/or portal hypertension
- Hyperammonaemia and/or high manganese levels → astrocyte changes
- Associated with acute liver failure, portosystemic bypass, cirrhosis
Signs and Symptoms| Grade | Mental Status | Asterixis | EEG |
|---|
| I | Euphoric/depressed, mild confusion, slurred speech, disordered sleep | May be present | Normal |
|---|
| II | Lethargy, moderate confusion | Present | Abnormal |
|---|
| III | Marked confusion, incoherence, somnolence but arousable | Present | Abnormal |
|---|
| IV | Coma | Absent | Abnormal |
|---|
Investigation
- Blood glucose
- Urea or BUN, creatinine, electrolytes
- Avoid LP (unless suspecting meningitis)
Management
- Excluding non-hepatic causes: intracranial lesion or infection, hypoglycaemia, electrolyte abnormalities or alcohol withdrawal
- Treat the precipitant: GI bleeding, metabolic diseases, infection, constipation
- Avoid CNS depressing medications e.g., benzodiazepines (treat overdose with flumazenil)
- Grade III or IV needs endotracheal intubation (for risk of aspiration)
- Specific points to reduce serum ammonia
- Protein restriction
- Lactulose: start with 30-40 g/d aim for 2-3 (loose) stools per day
- Short-term antibiotics (14 days): neomycin, metronidazole, vancomycin or rifaximin
- L-ornithine-L-asparagine 20 g/d (infused over 4 hours)
- Sodium benzoate 5g bid
Spontaneous Bacterial Peritonitis (SBP)
- Secondary infection of the ascitic fluid
- Incidence: 10-30% in cirrhosis patients, recurrence risk > 70%
- Common cause: Gram-negative bacilli (E. coli, Klebsiella spp.) 72%, Gram-positive cocci (Streptococcus spp.)28%
SBP should be suspected in patients with ascites with any of the following
- Temperature > 37.8°C
- Abdominal pain and/or tenderness
- A change in mental status
- Ascitic fluid PMN count ≥ 250 cells/mm3
Investigation
- Paracentesis (before antibiotic treatment)
- Ascitic fluid PMN count ≥ 250 cells/mm3
- Ascitic fluid culture +/- gram staining
Management for suspected or confirmed SBP
- Cefotaxime 2 g IV q 12 h OR
- Amoxicillin-clavulanate 1.2 g IV q 8 h
- Repeat paracentesis 24-48 hours post treatment
Prophylaxis
- All cirrhotic patients with UGIB should receive norfloxacin 400 mg po bid for 7 days (must r/o SBP before starting treatment)
- Previous SBP: norfloxacin 400 mg po od until liver transplant
Reference: Survival for All vol.1