Liver cirrhosis describes the irreversible end stage of liver disease where the liver is failing
Broad range of causes, most common- alcohol (ALD) and obesity (NAFLD)
Diagnosis: liver ultrasound + deranged synthetic function (bilirubin, albumin and prothrombin time)
Management: acute decompensation follow liver bundle, chronic management depends upon underlying cause
Liver damage follows: fatty liver -> hepatitis -> cirrhosis
Cirrhosis is irreversible
History
Reduced exercise tolerance
Fluid overload, distended abdomen
Alcohol excess
Examination
Ascites
RUQ tenderness
Jaundice
Spider naevi, finger clubbing, caput medusa, palmar eryhtema, duputyren's contrapture
Hypotensive
Investigations
Liver ultrasound- evidence of cirrhosis
Deranged LFTs
Ascitic tap: SAAG > 11
Diagnostic criteria: Liver US fibro scan (rarely liver biopsy)
Differentials: acute hepatitis
Classification (by severity):
Child Pugh Score: predicts liver cirrhosis mortality
Bilirubin
Albumin
INR
Ascites
Encephalopathy
Acute Decompensation of Liver Cirrhosis
Hepatic encephalopathy: lactulose 10mg TDS (2-3 soft stools/ day) & rifampicin
Ascitic tap +/- ascitic drain -> fluid microscopy ?SBP
Septic screen: CXR, viral PCR, blood and urine cultures, +/- CRP
Liver function: urea & electrolytes, liver function tests, coagulation studies; liver ultrasound
Baseline: FBC, Calcium, magnesium, phosphate
Slow IVF or HAS if hypovolemic
Consider
SBP: HAS 1.5mg/kg three days + IV Ceftriaxone
Alcohol withdrawal scale (AWS) and IV thiamine
Vte prophylaxis if platelets > 50
Long Term management
Treat underlying cause
Spironolactone + furosemide
Symptom: itch- cholestyramine
Commonest causes:
Alcoholic Liver Disease (ALD)
Core
Acute: Paracetamol Overdose , Viral Hepatitis
Genetic: Haemachromatosis , Wilson's Disease , Alpha Trypsin 1 Deficiency ,
Autoimmune: Autoimmune Hepatitis , Primary Biliary Cirrhosis (PBC) , Primary Sclerosing Cholangitis (PSC)
Drugs: amiodarone, methotrexate, steroids
Rarer
Defining Liver Decompensation
Encephalopathy (hyperuricemia)
GI bleeding- upper: melena & haematemesis, lower: PR bleeding
Jaundice- skin, eyes, raised bilirubin
Fluid overload- ascites, peripheral oedema
Portal hypertension:
Betablocker (non selective)- carvediolol
TIPS procedure
Oesophageal varices: endoscopic banding +- reduce portal hypertension
Oesophageal variceal bleed: co-amoxiclav & terlipressin
Hepatic encephalopathy: laxatives +++ (bowels 2-3/d), ammonia raised
Spontaneous bacterial peritonitis
IV Antibiotics (co-amoxiclav)
Human albumin solutin HAS- 1.5g/kg stat + rpt in 2d
Ascitic tap
Ascites- large volume paracentesis (LVP)
Liver cirrhosis is irreversible. Liver Transplants have the potential to cure however this resource is scarce and requires individuals to be fit enough to benefit.
Page written 2024.