Cirrhosis Lecture Notes

Introduction

Ninja Nerd Presenters: Discussing cirrhosis as part of the clinical medicine section.
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Cirrhosis: Irreversible fibrosis of the liver leading to a decline in liver function and potentially portal hypertension.
Basic Pathophysiology:
- Chronic liver injury → Hepatocyte destruction
- Stellate cells lay down fibrous and connective tissue in sinusoids
- Results in fibrosis and nodular regeneration
- Causes decline in liver function:
  - Albumin synthesis
  - Bilirubin conjugation
  - Ammonia clearance
  - Estrogen metabolism
  - Coagulation protein synthesis
- Compression of portal veins → Portal hypertension

Drugs (Alcohol): Most common; causes steatosis (fat accumulation)
Autoimmune Hepatitis: Treated with steroids; associated with antibodies (ANA, anti-smooth muscle, IGG, anti-LKM1)
Viral Hepatitis (B & C): Unsafe sex, IV drug use, blood transfusions (historical)
Metabolic Causes:
- Hemochromatosis: Iron buildup in liver and other tissues
- Wilson’s Disease: Copper accumulation
- Alpha-1 Antitrypsin Deficiency: Inactive polymers build up in liver causing injury
- Non-Alcoholic Fatty Liver Disease (NAFLD): Steatosis causing inflammation and fibrosis; associated with obesity, hypertension, hyperlipidemia

Right Heart Failure: Causes hepatic congestion due to backflow
Budd-Chiari Syndrome: Clots in hepatic veins causing congestion
Biliary Tract Diseases:
- Primary Biliary Cirrhosis/Cholangitis: Inflammation of intrahepatic bile ducts
- Primary Sclerosing Cholangitis: Inflammation of intra and extrahepatic bile ducts
- Associated with autoimmune conditions

Varices: Esophageal and gastric veins bulge, risk of rupture
- Upper GI bleed (hematemesis, melena)
- Portal-systemic shunts develop, bypassing liver processing
- Hyperammonemia: Can lead to hepatic encephalopathy (confusion, asterixis, cerebral edema)
Ascites: Fluid accumulation in peritoneal space due to increased hydrostatic pressure
- Characterized by abdominal distension, shifting dullness, fluid wave test
- Risk of spontaneous bacterial peritonitis (SBP): Fever, abdominal pain, elevated PMNs
Hepatorenal Syndrome: Renal artery vasoconstriction due to systemic blood flow issues

Decreased Albumin Production: Worsens ascites
Coagulopathy: Increased risk of bleeding due to reduced clotting factors
- Elevated INR
- Low platelets
Elevated Ammonia: Reduced clearance contributes to encephalopathy
Increased Estrogen Levels: Leads to clinical manifestations like gynecomastia, testicular atrophy, palmar erythema, spider angiomas
High Bilirubin Levels: Cause jaundice
Hepatocellular Carcinoma: Increased risk with cirrhosis, monitored by ultrasound and AFP levels

Labs:
- CBC, Liver Function Tests (LFTs), PT/INR, Albumin
- Indicators: Elevated AST, ALT (variable), high bilirubin, elevated PT/INR, low albumin, low platelets
Imaging:
- Abdominal ultrasound with elastography (liver stiffness)
Definitive Diagnosis: Liver biopsy showing nodular fibrosis

Ascites:
- Sodium restriction
- Diuretics: Spironolactone and furosemide
- Large-volume paracentesis with albumin replacement
- TIPS (Transjugular Intrahepatic Portosystemic Shunt)
Spontaneous Bacterial Peritonitis (SBP):
- Antibiotics (Ceftriaxone)
Hepatic Encephalopathy:
- Lactulose, rifaximin
Hepatorenal Syndrome:
- Octreotide, midodrine, albumin
Variceal Bleeding:
- Octreotide, beta-blockers (propranolol, nadolol), ceftriaxone, endoscopy for ligation
- TIPS for prevention
Hepatocellular Carcinoma:
- Regular abdominal ultrasound and AFP monitoring

Child-Pugh Score: Albumin, Bilirubin, Coagulation (INR), Ascites, Encephalopathy
MELD Sodium Score: Bilirubin, INR, Sodium, Creatinine, dialysis history