Cirrhosis - Medicine with Yugandhi

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Definition :

Cirrhosis is an end stage of any chronic liver disease.
It is a diffuse process characterized by Fibrosis and conversion of normal architecture to structurally abnormally regenerating nodules of liver cells.

Features :

Diffuse hepatic fibrosis and also nodule formation are the characteristic features of cirrhosis.
Moreover it can occur at any age of the life.
And also it is one of the important causes for premature death.
It has significant morbidity.
This is also the most common cause of portal hypertension and its complications.
The most common causes of cirrhosis are consumption of alcohol for a long period, chronic viral hepatitis, Non alcoholic fatty liver disease.
Apart from the above causes the condition which leads to persistent or reccurrent death of the hepatocytes leads to cirrhosis.
And also it results due to following reasons :
- Prolonged biliary damage and also in biliary obstruction
- Primary biliary cholangitis
- Primary sclerosing cholangitis
- Post biliary strictures
- Post surgical biliary strictures
- Persistent blockage of venous return from liver that occurs in sinusoidal obstruction syndrome
- And also Budd-Chiari syndrome

Pathophysiology :

After the injury of liver, Stellate cells in space of Disse starts to be active following the stimulation of cytokines secreted by the Kuppfer cells and hepatocytes.
This transforms the Stellate cells into Myofibroblast like cells.
These kind of Myofibroblast like cells are capable of producing collagen, pro-inflammatory cytokines and also other mediators that promote hepatocyte damage and tissue fibrosis.
Moreover cirrhosis of liver is a histological diagnosis.
This is a chronic condition and also evolves over longer period of time.
This evolves as a chronic condition along with fibrosis and also with widespread hepatocyte loss.
This leads to distortion of normal liver architecture.
Finally, this inturn leads to disruption of the vasculature of the liver and this inturn causes portosystemic shunts.
Moreover, all the above changes involves the whole of the liver.
But in case of primary biliary cirrhosis they can be patchy.
Cirrhosis can be classified histologically into :
- Micronodular cirrhosis
- And also Macronodular cirrhosis
Micronodular cirrhosis :
- Characteristics of micronodular cirrhosis is small nodules of 1mm in diameter – alcoholic cirrhosis.
Macronodular cirrhosis :
- Characterized by larger nodules of various sizes.
- Moreover areas of previous collapse are characterized by large fibrous scars.

Causes :

Firstly, Alcohol
Secondly, Chronic viral hepatitis (B or C)
Thirdly, Non alcoholic fatty liver disease
Immune :
- Primary sclerosing cholangitis
- And also autoimmune liver disease
Biliary :
- Primary biliary cholangitis
- Secondary biliary cirrhosis
- And also Cystic fibrosis
Genetic :
- Haemochromatosis
- Wilson’s disease
- Alpha-1 antitrypsin deficiency
- Cryptogenic
- Chronic venous outflow obstruction
- And also any chronic liver disease

Clinical features :

The clinical presentation of cirrhosis is highly variable.
Some patients remain asymptomatic and also are diagnosed during the surgery or during ultrasound incidentally.
Commonly patients present with hepatomegaly, splenomegaly, signs of portal hypertension or hepatic insufficiency.
When symptoms are present, they are often non-specific and include symptoms like weakness, fatigue, muscle cramps, weight loss, anorexia, nausea, vomiting and also upper abdominal discomfort.
Cirrhosis will also occassionally present because of shortness of breath due to large right pleural effusion, or with hepatopulmonary syndrome.
Hepatomegaly is common when the cirrhosis results due to alcoholism or haemochromatosis.
Progressive hepatocyte destruction and also fibrosis gradually reduces the size of the liver.
A reduction in liver size is common if the cause is viral hepatitis or autoimmune liver disease.
Liver is often hard, irregular, and also non-tender.
Jaundice is mild when it appears first.
And it is primarily due to failure of excretion of bilirubin.
Palmar erythema can be seen early but it is of limited diagnostic value.
Circulatory changes :
- Spider telangiectasia
- And also Cyanosis
Endocrine changes :
- Loss of libido
- Hair loss
- Men :
  - Testicular atrophy
  - Gynaecomastia
  - And also Impotence
- Women :
  - Breast atrophy
  - Irregular menses
  - And also Amenorrhoea
Haemorrhagic tendency :
- Bruises
- Epistaxis
- And also Purpura
Portal hypertension :
- Splenomegaly
- Collateral vessels
- And also Variceal bleeding
Hepatic encephalopathy
Finally, Other features :
- Pigmentation
- Digital clubbing
- And also Dupuytren’s contracture

Child – Pugh classification of prognosis in cirrhosis :

Score	1	2	3
Encephalopathy	None	Mild	Marked
Bilirubin	<68	60-170	>170
Albumin	< 35	28 – 35	< 28
Prothrombin time	< 4	4 – 6	> 6
Ascites	None	Mild	Marked

Add the individual scores :
- < 7 = Child’s A, 7-9 = Child’s B, > 9 = Child’s C

Management :

Firstly, Treatment of the underlying cause.
Once after the diagnosis, endoscopy is made to screen for oesophageal varices.
Patients to be on regular surviellance.
Cirrhosis + Chronic liver failure = Liver transplantation.

Prognosis :

Usually, Prognosis is usually poor.
Moreover most patients present in the end stage of the liver failure.
Laboratory tests give rough guide to prognosis in individual patients.
And also the Child – Pugh and MELD scores can be used to assess the prognosis.
Although, these scores give a guide to prognosis, the course of cirrhosis can be unpredictable.
This is due to complications such as the variceal bleeding and also due to many other complications.