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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

Cirrhosis of Liver

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.

MELD score

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