Cirrhosis

Fibrosis of the liver, most commonly caused by excessive alcohol consumption and Hepatitis C

Aetiology

Common causes:

  • Chronic alcohol abuse
  • Chronic viral hepatitis (HBV, HCV)
  • Non-alcoholic fatty liver disease (NAFLD/NASH)
  • Autoimmune hepatitis

Other causes:

  • Biliary cirrhosis (primary/secondary)
  • Hemochromatosis
  • Wilson disease (copper accumulation)
  • α-1 antitrypsin deficiency
  • Drug/toxin-induced (methotrexate, amiodarone)
  • Cardiac cirrhosis (right heart failure)

Pathophysiology

  1. Chronic inflammation (from chronic liver disease) damages the hepatic parenchyma
  1. Leads to activation of hepatic stellate cells in the space of Diss
  1. The HCSs increase fibrosis, leading to cirrhosis

Clinical presentation

Compensated

  • Patient appears clinically normal but has the histology of cirrhosis
  • Most commonly no clinical findings
  • May have:
    • Spider naevi
    • Palmar erythema
    • Clubbing
    • Gynaecomastia
    • Hepatomegaly (rarely)
    • Splenomegaly

Decompensated

  • Acute-on-chronic liver failure: precipitating event (e.g. bacterial infection, alcohol, DILI, viral hepatitis) → insult → systemic inflammatory response syndrome (SIRS)
    • If underlying cause is reversed, generally the liver will regenerate, and patient returns to pre-morbid state
  • End-stage liver disease: cirrhotic patient has insufficient hepatocytes to perform normal liver functions (+ no regeneration)
  • Clinical features include all of the above and:
    • Jaundice
    • Ascites
    • Encephalopathy
    • Easy bruising

Investigations

LFTs

  • Can be normal or elevated

Prothrombin time

  • Increased

Imaging

  • USS
  • CT/MRI
  • Transient elastography scan

Biopsy

  • Fibrosis
  • Gold standard but not necessary if other evidence is strong

Management

Compensated cirrhosis

  • Treat underlying cause
  • Avoid toxins (e.g. alcohol)
  • Balanced diet and B vitamins

Decompensated cirrhosis

  • Remove/treat underlying cause
  • Watch for NaCl retention
  • Nutrition - small frequent meals, energy and protein intake controlled, vitamin B supplementation (thiamine) for excess alcohol intake

Transplant

  • Patients generally require a UKELD score of ≳49 to be listed for elective liver transplant

Complications

  • Blood flow to liver is reduced so liver function is decreased → decreased blood detoxification leads to hepatic encephalopathy
  • Because liver is fibrous, blood can’t leave the portal system very easily → portal hypertension → ascites, oesophageal varices, anorectal varices, caput medusa
  • Increased risk of hepatocellular carcinoma