Cirrhosis

Hepatic cirrhosis is the reconstruction of the lobular structure of the liver into a nodular structure ( hepatocyte death , replaced by connective tissue, the remaining parenchyma regenerates + forms nodules) as a result of chronic liver disease.

Etiology

• chronic hepatitis C, B, B + D - posthepatitic cirrhosis ,
• alcoholic liver damage - alcoholic cirrhosis ,
• long-term biliary obstruction - biliary cirrhosis ,

• primary - autoimmune diseases ( antibodies against interlobular bile ducts are formed ),
• secondary - due to prolonged biliary obstruction by tumor or concretion ,
• primary sclerosing cholangitis - autoimmune disease of intrahepatic and extrahepatic bile ducts,

• toxic liver damage ( paracetamol , amatoxin…) - toxic cirrhosis,
• metabolic diseases ( Wilson's disease , α1-antitrypsin deficiency, hemochromatosis , porphyria , CF and others),
• long-lasting venostasis - cirrhosis due to venous congestion,
• unclear etiology - cryptogenic cirrhosis (in 10–15%).

The consequences of liver cirrhosis (and underlying complications) are:

• impaired synthetic function of the liver (especially proteosynthesis ) by the death of hepatocytes - liver insufficiency ,
• portal hypertension .

Complications of cirrhosis

thumb|vpravo|300px|Mikronodulární jaterní cirhóza

• portal hypertension - congestion in the Vena portae basin, consequences:

• esophageal varices - massive bleeding ( hematemesis , melena )
• ascites - fluid and sodium retention by the kidneys ( hyperaldosteronism - impaired degradation in the liver), hypoproteinemia is less important
• splenomegaly - platelet sequestration in the spleen - thrombocytopenia

reduced resistance to infection (limited blood flow to the liver eliminates liver RES ) - pneumonia , SBP

• bleeding ( hemorrhagic diathesis ) - insufficient synthesis of coagulation factors , hypersplenism with thrombocytopenia
• jaundice - not always expressed
• spider nevi (naevus araneus, extension of the terminal sections of skin arterioles) - especially on the hands, forearms, forehead and front of the chest
• liver failure
• renal failure ( hepatorenal syndrome )
• hepatocellular carcinoma
• hyperestrism - a disorder of the breakdown of estrogen by the liver, excess leads to testicular atrophy and gynecomastia in men, and menstrual disorders and ovarian atrophy in women
• encephalopathy

Clinical picture

Hepatic cirrhosis can be asymptomatic for a long time and is diagnosed at random (preventive examinations, abdominal surgery, etc.).

Compensated cirrhosis (latent subclinical)

• very reminiscent of chronic hepatitis
• subjectively , patients complain of non-specific symptoms: dyspepsia - feelings of fullness after eating, stool changes; in women menses disorders, hypomenorrhea to amenorrhea
• objectively : hepatosplenomegaly , slow-growing portal hypertension , skin symptoms - spider nevi, manifestations of bleeding, mild perimalleolar swelling , nocturia, sudden hematemesis

Decompensated cirrhosis (advanced)

• varied symptomatology
• symptoms of parenchymatous liver disorders (metabolic decompensation) - jaundice , hemorrhagic diathesis , hypoalbuminemia with fluid retention with ascites and edema
• symptoms of advanced portal hypertension (vascular decompensation) - ascites, esophageal varices , portosystemic encephalopathy
• subjectively - insurmountable fatigue, weakness, exhaustion, loss of appetite, weight loss, abdominal enlargement, swelling; in women menses to amenorrhoea disorders, in men decreased libido and potency, gynecomastia, often arthralgia and spine pain
• objectively - patient tired, emaciated (large abdomen, thin limbs), slow reactions (encephalopathy), subfebrile, hypothermia or isothermia, skin pale, often icteric, numerous spider nevi , lips and tongue are red (varnished), palmar erythema on the hands, Dupuytren's contracture , white nails, clubbed fingers , hemorrhagic diathesis (petechiae, hematomas, bleeding from the gums, nose, gynecological), in men the chest hair disappears ( Tail's habitus ), gynecomastia

Physical finding:

• aspects: arching of the right lower jaw , jaundice, spider nevi, palmar erythema, etc.
• palpation: splenomegaly, may be hepatomegaly
• percussion: may be hepatomegaly, evidence of ascites (glacial symptom)

Diagnosis

thumb|350px|Mikroskopický obraz jaterní cirhózy

• anamnesis and physical examination
• laboratory examination

• increased AST and ALT , hyperbilirubinemia
• thrombocytopenia, leukopenia (hypersplenism)
• hypoalbuminemia, hypergammaglobulinemia, ↑ erythrocyte sedimentation
• prolongation of prothrombin time
• decompensation of cirrhosis results in an increase in ammonia and a decrease in uremia
• in biliary cirrhosis, obstructive enzymes ( ALP , GMT )
• hepatitis serology
• autoantibodies in autoimmune cirrhosis
• AFP in the transition to cancer

• imaging methods ( ultrasound or CT of the liver, endoscopy to detect varicose veins)
• liver biopsy

Treatment

1. influencing the underlying disease – abstinence in alcoholics , treatment of hepatitis , penicillamine in Wilson's disease
2. supportive measures – regime measures (alcohol abstinence, omission of hepatotoxic drugs), administration of vitamins A, D, E, [[vitamin K|K], hepatoprotectants, in autoimmune hepatitis (nowhere else) corticoids are given
3. liver transplantation
4. treatment of complications:

• bleeding from esophageal varices (endoscopic sclerosing or ligation + terlipressin (Remestyp), in case of TIPS failure or surgery, after bleeding GIT and ATB lavage , preventive administration of non-selective β-blockers and nitrates)
• hepatic encephalopathy (restriction of protein intake, lactulose, ATB, administration of branched-chain amino acids )
• ascites (restriction of fluid and salt intake, diuretics (spironolactone + furosemide), puncture, TIPS, shunt)
• hepatorenal syndrome (Remestype in combination with iv albumin)
• hepatocellular carcinoma (surgical resection or radiofrequency ablation, palliative chemoembolism)

Prognosis

The Child-Pugh score is used to predict liver cirrhosis.

Score used to evaluate the prognosis of a patient with chronic liver failure. MediaWiki:Lékařská kalkulačka/Child-Pugh

References

Related Articles

• Pseudolobular cirrhosis (specimen)

External links

• Cirhóza – video na YouTube.com vysvětlující patofyziologii a komplikace cirhózy