Cirrhosis of liver

 Characterized by:
 Extensive fibrosis
 Regeneration nodules

 Cirrhosis-final common pathway of many

types of chronic liver injury
 Cirrhosis of liver

 The end product of the rxn of the liver to

certain types of injury.
 The rate at which the liver is injured
varies.
 Cirrhosis of liver
 Pathophysiology:
 Liver cell dysfunction:
• Jaundice
• Oedema
• Coagulopathy
• Metabolic abnormalities

 Fibrosis and distorted vasculature:

• Portal hypertension: varices,splenomegaly

 Hepatocellular insufficiency ascites

Portal hypertension hepatic
encephlopathy
 Cirrhosis of liver

 Classification:
 Alcoholic
 Cryptogenic & postviral or postnecrotic
 Biliary
 Cardiac
 Metabolic,inherited and drug related
 Miscellaneous
 Cirrhosis of liver

 Alcoholic cirrhosis:(Laennec or
micronodular cirrhosis)
 3 types of lesion:
• Fatty liver
• Hepatitis
• Cirrhosis
• A pint of whisky for 10 years - cirrhosis
 Cirrhosis of liver

 Normal  Alcoholic Liver

Cirrhosis of liver
Fatty yellow liver
Cirrhosis of liver
Fatty liver
Cirrhosis of liver
Fatty liver
 Cirrhosis of liver

 Fatty liver – hepatomegaly

 Alcoholic hepatitis:
 Resembles viral hepatitis
 Anorexia,nausea,vomiting
 Wt.loss,jaundice
 Tender hepatomgaly,spider angioma
 Ascites,edema,bleeding
 Encephalopthy
 Histological abnormality up to 6 months
 Cirrhosis of liver

 Alcoholic cirrhosis:
 Anorexia,weight loss
 Bleeding from varices
 Ascites,encephalopathy
 Palpable,firm nodular liver
 Jaundice
 Palmar erythema,spider angioma
 Parotid & lacrimal enlargement
 Clubbing,splenomegaly
 Cirrhosis of liver

 Alcoholic cirrhosis:
 Decreased body hair,gynaecomazia
 Testicular atrophy
 Dupuytren’s contracture
(fibrosis of palmar fascia)

Most pts. die in hepatic coma

Cirrhosis of liver

Jaundice
Cirrhosis of liver
Jaundice
Cirrhosis of liver
Clubbing
 Cirrhosis of liver
Spider angioma and palmar erythema
Cirrhosis of liver
Palmar erythema
 Cirrhosis of liver
Micronodular cirrhosis-alcoholic
 Cirrhosis of liver

 Treatment:
 Supportive
 Large doses of steroids in encephalopathy
 Colchicine 0.6mg b.i.d
(slows progression of disease)
 Protein 1gm/kg, 2000-3000 cal.diet
 Multivitamin supplements
 Cirrhosis of liver

 Postnecrotic postviral cirrhosis:(Coarsely

nodular,posthepatitic,multilobular)
 Liver shrunken in size

 Distorted in shape

 Nodules of liver cells separated by broad

bands of fibrosis
 Cirrhosis of liver
Pale liver with fibrosis and nodules
Cirrhosis of liver

Liver cirrhosis-CT scan

Cirrhosis of liver
Liver cells and fibrous tissue
Cirrhosis of liver
Fibrosis
 Cirrhosis of liver

 Causes of postnecrotic cirrhosis:

 Infectious diseases:
• Viral hepatitis
• Schistosomiasis
 Inherited & metabolic disorders:
• Hemochromatosis
• Wilson’s disease
• Glycogen storage disease
 Cirrhosis of liver

 Causes of postnecrotic cirrhosis:

 Drugs:
• Methyldopa
• Methotrexate
• Isoniazid
• Oral contraceptives
 Others:
• Sarcoidosis
• Cystic fibrosis
• Diabetes mellitus
 Cirrhosis of liver

 Postnecrotic cirrhosis:
 Clinical features related to portal hypertension
and sequale
 Needle biopsy confirms the diagnosis
 Treatment:
 Control of ascites
 Prompt treatment of infections
 Avoidance of drugs ppting. coma
 Cirrhosis of liver

 Biliary cirrhosis:
 Results from injury or obstruction to
intrahepatic or extrahepatic biliary system
 Primary:obliteration of intrahepatic bile
ductules
 Secondary:obstruction of large extrahepatic
ducts
 Cirrhosis of liver

 Primary biliary cirrhosis:

 Autoimmune
 IgG antimitochondrial antibody
 Lymphocytes in portal regions
 4 stages: chronic cholangitis
proliferation of smaller bile ductules
periportal fibrosis
cirrhosis:micro or macronodular
 Cirrhosis of liver
 Primary biliary cirrhosis:
 Clinical features:
• Women aged 35-60 yrs.
• Pruritus and jaundice
• Darkening of exposed areas of skin
• Easy bruising
• Bone pain due to osteomalacia
• Night blindness and dermatitis
• Xanthelesma and xanthoma
• Clubbing
• Hepatomegaly and splenomegaly
• Ecchymosis,glossitis,dermatitis
 Cirrhosis of liver

 Primary biliary cirrhosis:

 Laboratory findings:
• ↑ Alkaline PO4-ase
• ↑Serum 5-nucleotidase
• Bilirubin and aminotransferases normal
• +ve antimitochondrial antibody
• Hyperlipidemia
 Cirrhosis of liver

 Primary biliary cirrhosis:

 Colchicine 0.6 mg b.i.d
 Low dose methotrexate
 Cholestyramine 6-12 gm./day
 Low fat diet
 Inj.Vitamin A & K
 Zinc supplementation
 Dietary calcium and vitamin D
 Hepatic transplantation in end stage disease
 Cirrhosis of liver
 Secondary biliary cirrhosis:
 Obstruction of CBD or its branches by
• Post-op.stricture or bile stones
• Chronic pancreatitis
• Idiopathic sclerosing cholangitis
• Congenital biliary atresia
• Choledochal cysts
 Clinical features & lab tests similar to PBS
 Diagnosis: cholangiography(endoscopic or
percutaneous)
 Treatment: relieve obstruction by surgery or
endoscopy
antibiotics in recurrent cholangitis
 Cirrhosis of liver

 Cardiac cirrhosis:
 Chronic CHF→Cirrhosis
• Centrilobular fibrosis
• Collagen in stellate pattern from central vein
• Alternating red and pale areas (nutmeg liver)
 Cirrhosis of liver

Major sequalae of cirrhosis:

1. Portal hypertension
2. Ascites
3. Hepatic encephalopathy
4. Spontaneous bacterial peritonitis
5. Hepatorenal syndrome
6. Hepatocellular carcinoma
 Cirrhosis of liver

 Portal hypertension:
 Normal portal vein pressure: 10-15 cm.
normal saline
 Portal hypertension→ › 30 cm. normal saline

PHT
-presinusoidal : portal vein thrombosis
-sinusoidal : cirrhosis (commonest cause)
-postsinusoidal : hepatic vein obstruction (Budd-
Chiari syndrome)
Cirrhosis of liver
Cirrhosis of liver
 Cirrhosis of liver
 Portal hypertension :
 Clinical features:
• Haemorrhage from gastro-oesophagial varices
• Splenomegaly with hypersplenism
• Ascites
• Acute and chronic hepatic encephalopathy
 Collaterals :
• Around rectum (hemorrhoids)
• Cardio-oesophagial junction(gastric oesophagial varices)
• Retroperitoneal space
• Falsiform ligament of liver(periumbilical or abdominal wall
collaterals)→ Caput medusa
Cirrhosis of liver
COLLATERALS IN PORTAL HYPERTENSION

Cirrhosis of liver
Cirrhosis of liver
Ascites and collaterals
 Cirrhosis of liver

 Portal hypertension :
 Diagnosis :
• Varices by barium swallow or endoscopy
• Portal vein pressure measured by percutaneous
transhepatic cholangiography
• Mesenteric and hepatic encephalopathy
 Treatment :
• Portal systemic shunt surgery
• Propranolol (to reduce the resting pulse by 25 %)
 Cirrhosis of liver
Treatment of Portal
Hypertension
 Nitric Oxide – vasodilator that decreases intrahepatic
Nitric Oxide – vasodilator that decreases intrahepatic
resistance
 Something that is normally found in the liver but levels decrease
in a cirrhotic liver
 Drug therapies are being looked at to provide NO to the liver
only
 Transjugular intrahepatic portosystemic shunt (TIPS) –
catheter is extend from portal vein across liver and
connects to the hepatic vein
 Portacaval Shunts – pass blood from portal vein to
inferior vena cava
 High death rate
 24-53% show debilitating symptoms of hepatic encephalopathy
 Cirrhosis of liver

 Variceal bleeding :
 Painless but massive bleeding
 Treatment :
 Vasoconstrictors : Vasopressin 0.1-0.9 units/min I.V
infusion
 Replacement of clotting factors by fresh frozen
plasma
 Balloon tamponade : Sengstaken-Blackmore tube
 Endoscopic sclerosis of oesophageal varices
 Portal systemic shunt surgery
Cirrhosis of liver
 Cirrhosis of liver

 Ascites : accumulation of excessive fluid

within peritoneal cavity
 Increase in abdominal girth
 Dyspnoea
 Fluid thrill or shifting dullness
 Ultrasonography
 Paracentesis is diagnostic
 Cirrhosis of liver

 Ascites :
 Treatment :
• Strict bed rest
• salt restriction
• Diuretic therapy : spiranolactone or triamterene or
amiloride
+
frusemide
• I.V infusion of salt poor albumin
• Porta-caval shunt
Cirrhosis of liver
 Cirrhosis of liver

 Spontaneous bacterial peritonitis:

 Abrupt fever , chills, generalised abdominal
pain and rebound tenderness
 Leucocyte count : 500 /cu.mm.
 PMN : 250 /cu.mm.
 Ascitic fluid culture :
• Enteric gram –ve bacilli in majority of cases
 Treatment : antibiotic for 10-14 days
 Cirrhosis of liver
 Hepato-renal syndrome:
 Worsening azotemia and Na+ retention
 Oliguria in the absence of renal disease
 Imbalance in metabolites of arachidonic
acid(prostaglandin and thromboxane)
 Precipitating factors: GI bleed , sepsis, vigorous
diuresis
 Urinary sodium less than 5 mmol/litre
 Urinary sediment is unremarkable
 Treatment: unsuccessful
: infusion of salt poor albumin
 Cirrhosis of liver

 Hepatic encephalopathy:
 A complex neuro-psychiatric syndrome
 Characterised by :
• Disturbances in consciousness and behaviour
• Personality changes
• Fluctuating neurological signs
• Asterixis
• Distinctive ECG changes
 Cirrhosis of liver

 Hepatic encephalopathy:
 Acute or chronic
 Specific cause unknown
 Accumulation of toxic metabolites:
• Ammonia
• Mercaptans
• Short chain fatty acids
• Phenol
• CNS GABA
• False neuro-chemical transmitters: Octopamine
Cirrhosis of liver
 Cirrhosis of liver

 Hepatic encephalopathy:
 Precipitating factors :

• Increased nitrogen load : GI bleed, Azotemia

• Electrolyte imbalance: hypokalemia, alkalosis
• Drugs : Narcotics, Diuretics
• Miscellaneous : infection and surgery
 Cirrhosis of liver

 Clinical grading of hepatic encephalopathy

 Grade 1. Confused. Altered mood or behaviour.

Psychometric defects.
 Grade 2. Drowsy. Inappropriate behaviour.
 Grade 3. Stuporose but speaking and obeying simple
commands. Inarticulate speech. Marked confusion
 Grade 4. Coma. Cannot be aroused.
 Cirrhosis of liver

 Hepatic encephalopathy:
 Clinical features:
• Acute or chronic hepatocellular disease and/or extensive
portal systemic collaterals
• Disturbances of mentation : confusion, stupor and coma
• Shifting neurological signs:
 Asterixis,Rigidity, hyper-reflexia
 Extensor plantar sign, seizures
• Symmetric high voltage slow wave pattern in EEG
• Fetor hepaticus (musty odour due to mercaptans)
• Spastic paraparesis
 Cirrhosis of liver

 Hepatic encephalopathy:
 Treatment :
• Supportive measures for coma patient
• Evacuate the blood in the bowel with enema
• No protein in diet
• Oral lactulose prevents ammonia absorption
(30-50 ml hourly until diarrhoea occurs)
• Oral neomycin (0.5 – 1 gm Q6H)
• Levodopa, bromocriptine of unproven value
Cirrhosis of liver