Cirrhosis overview: Difference between revisions
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Revision as of 16:04, 12 July 2017
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Cirrhosis Microchapters |
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Diagnosis |
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Treatment |
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Case studies |
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Cirrhosis overview On the Web |
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American Roentgen Ray Society Images of Cirrhosis overview |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Charmaine Patel, M.D. [2] Aditya Govindavarjhulla, M.B.B.S. [3]
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Overview
Cirrhosis is a consequence of chronic liver disease characterized by the replacement of liver tissue by fibrotic scar tissue as well as regenerative nodules, leading to progressive loss of liver function. Cirrhosis is most commonly caused by alcoholism and hepatitis C, but has many other possible causes.
Ascites (fluid retention in the abdominal cavity) is the most common complication of cirrhosis and is associated with a poor quality of life, increased risk of infection, and a poor long-term outcome. Other potentially life-threatening complications are hepatic encephalopathy (confusion and coma) and bleeding from esophageal varices. Cirrhosis is generally irreversible once it occurs, and treatment generally focuses on preventing progression and complications. In advanced stages of cirrhosis the only option is a liver transplant.
Historical Perspective
Classification
Pathophysiology
Cirrhosis occurs due to long term liver injury which causes an imbalance between matrix production and degradation. Early disruption of the normal hepatic matrix results in its replacement by scar tissue, which in turn has deleterious effects on cell function.
Causes
There are a wide range of causes for cirrhosis, including alcohol abuse, genetic diseases, cardiac causes, toxins, viruses, and malnutrition. The consequence to the liver is the same in all cases however, with the functioning liver tissue being replaced by non-functioning scar tissue.
Differentiating Cirrhosis from other Diseases
Cirrhosis can present in a similar way to some other diseases. History, physical examination, and diagnostic testing can help to differentiate cirrhosis from other diseases such as malignancy, constrictive pericarditis, Budd-Chiari syndrome, portal vein thrombosis and splenic vein thrombosis.
Epidemiology and Demographics
The most common cause of cirrhosis in the United States is chronic and heavy alcohol use, while the most common cause of cirrhosis worldwide is the hepatitis virus. Cirrhosis and chronic liver disease is the 12th leading cause of death United States.
Risk Factors
Certain aspects of genetics and lifestyle can put someone at risk for cirrhosis. Chronic alcohol use, or the development of a fatty liver can put one at risk for cirrhosis. Genetic diseases such as cystic fibrosis, and hemochromatosis, and not genetic diseases such as hepatitis B and hepatitis C, are also significant risk factors for the development of cirrhosis.
Screening
Natural History, Prognosis and Complications
Cirrhosis is an irreversible process, the course of which is highly variable from patient to patient. The natural history progresses so that there is a lengthy stage of compensation, followed by development of complications and sequelae as a result of the cirrhosis. The devastating complications include complete liver failure or the development of hepatocellular carcinoma. Other complications are portal hypertension, ascites, jaundice, itching, esophageal varices, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome and cardiomyopathy. Prognosis depends on the causes, existing complications and a variety of factors which make prediction of life expectancy questionable. There are scores by which to classify severity and to determine suitability for liver transplant.
Natural History
Complications
Prognosis
Diagnosis
Diagnostic Criteria
History and Symptoms
The diagnosis of liver cirrhosis requires accurate knowledge of abuse of alcohol by the patient. Other causes of cirrhosis (eg: Hepatitis B and C, metabolic or autoimmune cause) also need to be determined to better understand the prognosis and treatment of the cirrhosis.
Physical Examination
Many signs and symptoms may occur in the presence of cirrhosis or as a result of the complications or causes of cirrhosis. Many are nonspecific and may occur in other diseases and do not necessarily point to cirrhosis. Likewise, the absence of any sign or symptom does not rule out the possibility of cirrhosis.
Laboratory Findings
A range of laboratory values need to be obtained in the evaluation of cirrhosis, both to determine the severity of the disease, and to determine the causative factor. Liver function tests, complete blood count, basic metabolic panel and coagulation factors are standard in the evaluation of cirrhosis. More specific testing for markers and serum enzymes can be done when certain genetic causes and etiologies are suspected.
Imaging Findings
Electrocardiogram
In a few patients with cirrhosis, circulating toxins may cause the ECG to show prolongation of the QT interval. Low voltage complexes in the precordial leads can also be noticed in patients with fluid overload.
Chest X Ray
Chest x ray has a limited role in the diagnosis and management of cirrhosis, but can be helpful in identifying certain complications that can occur as a result of cirrhosis.
CT
Although CT scans are not routinely used in evaluation and diagnosis of cirrhosis, it can show the presence of lobar atrophic and hypertrophic changes in the liver, as well as ascites and varices in advanced disease. CT can also visualize the presence of tumors and blocked bile ducts, as well as evaluate the size of the liver.
Echocardiography or Ultrasound
On ultrasonography, changes in liver contours and nodularity may be evident. The echo texture may appear coarsened along with increase in echogenecity from focal fatty changes and irregular appearing areas. It can also be used to screen for hepatocellular carcinoma, portal hypertension and Budd-Chiari syndrome.
Other Imaging Findings
Tc-99m labeled sulfur can be used in nuclear imaging to obtain an indication of hepatic function. CTA is used to asses the drainage of the liver, when assessing a patient for liver transplant.
All patients with cirrhosis should undergo a diagnostic endoscopy for the evaluation of varices. Gastric endoscopy is also an option if gastric varices are suspected, and endoscopic ultrasound can also help in the visualization of varices. ERCP can be done if biliary pathology as a cause of the cirrhosis is suspected.
Other Diagnostic Studies
The gold standard diagnostic test for cirrhosis is liver biopsy, although it is rarely necessary for diagnosis or treatment. NT-proBNP can be used to evaluate the complications of cirrhosis.
Treatment
The change that cirrhosis causes to the liver is irreversible, therefore treatment is mostly centered on the ameliorating the complications of cirrhosis. This entails treating pain, osteoporosis, hypogonadism, constipation, itching, malnutrition, as well as any identified underlying causes.
Medical Therapy
Surgery
Prevention
Prevention includes avoiding agents that can cause cirrhosis, such as alcohol. Avoidance of high doses of certain supplements (vitamin A, copper and iron can also prevent cirrhosis, as can getting vaccinated against hepatitis. Eating a healthy diet, getting exercise, and maintaining a healthy weight, can also help in preventing cirrhosis.