Cirrhosis: Difference between revisions
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[[File:Auscities.png|thumb|Ascites appearance on ultrasound]] | [[File:Auscities.png|thumb|Ascites appearance on ultrasound]] | ||
[[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites on CT]] | [[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites on CT]] | ||
===Workup=== | |||
*CBC | |||
*Chem 7 | |||
*PT/PTT | |||
*[[LFTs]] + lipase | |||
*[[FAST]] | |||
====Ascites Fluid Workup==== | |||
*Cell count and differential | |||
*Albumin | |||
*Total protein | |||
*Only if suspicious:<ref name=Runyon2012>Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.</ref> | |||
**[[Gram stain]] | |||
**Glucose | |||
**LDH | |||
**Amylase | |||
**AFB smear and culture | |||
**Cytology | |||
**Triglyceride | |||
{{Ascites Evaluation}} | |||
==Management== | ==Management== | ||
Revision as of 19:47, 7 September 2022
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]
Causes
- 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
Clinical Features
Ascites secondary to cirrhosis.
- May be asymptomatic initially
- Malaise, weakness (from electrolyte derangements)
- Abdominal pain
- Ascites, SBP (fever, abdominal tenderness)
- Altered mental status due to hepatic encephalopathy
- Coagulopathy
- GI bleed
Differential Diagnosis
Abdominal distention
- Obesity
- Intestinal obstruction
- Pregnancy
- Ascites
- Cirrhosis
- Malignancy
- Heart failure
- Tuberculosis
- Spontaneous bacterial peritonitis
- Peritoneal dialysis-associated peritonitis
- Distended bladder / Acute urinary retention
- Constipation / fecal impaction
- Large tumor(s) (e.g. ovarian, lymphoma)
- Organomegaly
Evaluation
Workup
Ascites Fluid Workup
- Cell count and differential
- Albumin
- Total protein
- Only if suspicious:[2]
- Gram stain
- Glucose
- LDH
- Amylase
- AFB smear and culture
- Cytology
- Triglyceride
Ascites Diagnosis
The differential diagnosis of ascites is often clarified by the calculation of the serum albumin to ascites gradient (SAAG).^
- High SAAG > 1.1 g/dL – Indicative of portal hypertension[3]
- Cirrhosis
- Heart failure
- Ascites total protein > 2.5 g/dL suggests cardiac ascites[4]
- Alcoholic hepatitis
- Budd-Chiari syndrome
- Portal vein thrombosis
- Low SAAG < 1.1 g/dL
- Malignancy / peritoneal carcinomatosis
- Nephrotic syndrome
- Pancreatitis
- Peritoneal tuberculosis
- Serositis
- Bowel infarction
- Chylous
- ^SAAG = (serum albumin in g/dL) − (ascitic albumin in g/dL)
Management
Complications of cirrhosis
- Ascites
- Esophageal varices
- Hepatic encephalopathy
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome
- Portal hypertension
- Upper gastrointestinal bleed
- 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
Prognosis
Child-Pugh Score[5]
| +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[6]
| MELD-Na Score | 3-month mortality |
|---|---|
| 40 | 71.3% |
| 30-39 | 52.6% |
| 20-29 | 19.6% |
| 10-19 | 6.0% |
| <9 | 1.9% |
See Also
External Links
References
- ↑ Heron M. Deaths: Leading Causes for 2013. Natl Vital Stat Rep 2016: 16;65(2):1-95.
- ↑ Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
- ↑ Runyon BA. Management of adult patients with ascites due to cirrhosis: update 2012. Amer Assoc Study Liv Dis. 2012; 1-96.
- ↑ Runyon BA. Cardiac ascites: a characterization. J Clin Gastro. 1998; 10(4): 410-412.
- ↑ 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.