Cirrhosis: Difference between revisions
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==Background== | ==Background== | ||
*A generally irreversible fibrotic | *A generally irreversible fibrotic scarring of the liver parenchyma resulting in liver failure | ||
*The twelfth leading cause of death in men and women in 2013<ref>Heron M. Deaths: Leading Causes for 2013. Natl Vital Stat Rep 2016: 16;65(2):1-95.</ref> | *The twelfth leading cause of death in men and women in 2013<ref>Heron M. Deaths: Leading Causes for 2013. Natl Vital Stat Rep 2016: 16;65(2):1-95.</ref> | ||
==Clinical Features== | ==Clinical Features== | ||
*May be asymptomatic initially | |||
*Malaise, weakness (from electrolyte derrangements) | |||
*[[Abdominal pain]] | |||
*[[Ascites]], [[SBP]] (fever, abdominal tenderness) | |||
*[[Altered mental status]] due to [[hepatic encephalopathy]] | |||
*Coagulopathy | |||
*[[GI bleed]] | |||
===Child-Pugh Score[http://www.mdcalc.com/child-pugh-score-for-cirrhosis-mortality/ <ref>Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64</ref>]=== | ===Child-Pugh Score[http://www.mdcalc.com/child-pugh-score-for-cirrhosis-mortality/ <ref>Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64</ref>]=== | ||
{| class="wikitable" | {| class="wikitable" | ||
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*Portal hypertension | *Portal hypertension | ||
*Hepatocellular carcinoma | *Hepatocellular carcinoma | ||
'''Pain management in cirrhotic patients''' | |||
*[[Acetaminophen]] is safe for short-term use at reduced dose of 2 grams total per day | |||
*[[Gabapentin]] or pregabalin for neuropathic pain | |||
*Avoid [[NSAIDs]] | |||
*Avoid [[opioids]] | |||
**unpredictable effects if liver function impaired due to hepatic metabolism | |||
**if necessary, [[fentanyl]] or [[tramadol]] probably safest | |||
==Disposition== | ==Disposition== | ||
Revision as of 22:19, 28 September 2016
Background
- A generally irreversible fibrotic scarring of the liver parenchyma resulting in liver failure
- The twelfth leading cause of death in men and women in 2013[1]
Clinical Features
- May be asymptomatic initially
- Malaise, weakness (from electrolyte derrangements)
- Abdominal pain
- Ascites, SBP (fever, abdominal tenderness)
- Altered mental status due to hepatic encephalopathy
- Coagulopathy
- GI bleed
Child-Pugh Score[2]
| +1 | +2 | +3 | |
|---|---|---|---|
| Bilirubin | <2mg/dL | 2-3mg/dL | >3 Mg/dL |
| Albumin | >3.5mg/dL | 2.8-3.5mg/dL | <2.8mg/dL |
| INR | <1.7 | 1.7-2.2 | >2.2 |
| Ascites | No ascites | Ascites, medically controlled | Ascites, poorly controlled |
| Encephalopathy | No encephalopathy | Encephalopathy, medically controlled | Encephalopathy, poorly controlled |
- Score ≤ 7 = Class A = 100% and 85% one and two-year patient survival
- Score 7 - 9 = Class B = 80% and 60% one and two-year patient survival
- Score ≥ 10 = Class c = 45% and 35% one and two-year patient survival
MELD Score[3]
| MELD-Na Score | 3-month mortality |
|---|---|
| 40 | 71.3% |
| 30-39 | 52.6% |
| 20-29 | 19.6% |
| 10-19 | 6.0% |
| <9 | 1.9% |
Differential Diagnosis
- Hepatitis chronic B and C
- Alcoholic liver disease
- Non-alcoholic steatohepatitis
- Drug induced (ie. Tylenol. amiodarone, NRTIs])
- Cardiac Cirrhosis
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Autoimmune Hepatitis
- Alpha1 anti-trypsin Deficiency
- Cystic Fibrosis
Management
Complications of cirrhosis
- Ascites
- Esophageal varices
- Hepatic encephalopathy
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome
- Portal hypertension
- Hepatocellular carcinoma
Pain management in cirrhotic patients
- Acetaminophen is safe for short-term use at reduced dose of 2 grams total per day
- Gabapentin or pregabalin for neuropathic pain
- Avoid NSAIDs
- Avoid opioids
Disposition
- Often complex and should be based on presence/absence of acute complications
- If no complications present, discussion with patient's primary care provider or gastroenterologist recommended
See Also
External Links
References
- ↑ Heron M. Deaths: Leading Causes for 2013. Natl Vital Stat Rep 2016: 16;65(2):1-95.
- ↑ Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64
- ↑ Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D'Amico G, Dickson ER, Kim WR. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001 Feb;33(2):464-70.