Cirrhosis: Difference between revisions

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===Background===
==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<ref>Heron M. Deaths: Leading Causes for 2013. Natl Vital Stat Rep 2016: 16;65(2):1-95.</ref>


===Differential===
===Causes===
*[[Hepatitis]] chronic B and C
*Alcoholic liver disease
*[[Non-alcoholic steatohepatitis]]
*Drug induced (ie. [[Tylenol]]. [[amiodarone]], NRTIs])
*[[Congestive heart failure (CHF)|Cardiac Cirrhosis]]
*Primary biliary cirrhosis
*[[Primary sclerosing cholangitis]]
*[[Autoimmune hepatitis]]
*Alpha1 anti-trypsin Deficiency
*[[Cystic Fibrosis]]


===Clinical Features===
==Clinical Features==
[[File:Jaundice08.jpg|thumb|Jaundice of the skin]]
[[File:SpiderAngioma.jpg|thumb|Spider angioma]]
[[File:Hepaticfailure.jpg|thumb|[[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]]
*[[liver disease induced coagulopathy|Coagulopathy]]
*[[GI bleed]]


===Management===
==Differential Diagnosis==
{{DDX abdominal distention}}


===Disposition===
==Evaluation==
[[File:Auscities.png|thumb|Ascites appearance on ultrasound]]
[[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites on CT]]
 
==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]]
**unpredictable effects if liver function impaired due to hepatic metabolism
**if necessary, [[fentanyl]] or [[tramadol]] probably safest
 
==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[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"
|-
!  !! +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
<br />
===MELD Score[http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/ <ref>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.</ref>]===
{| class="wikitable"
|-
! 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==
*[[Viral hepatitis]]
*[[Acute hepatic failure]]
*[[Jaundice]]
*[[Ascites]]
 
==External Links==
 
==References==
<references/>
 
[[Category:GI]]

Revision as of 18:15, 4 June 2020

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

Clinical Features

Jaundice of the skin
Spider angioma
Ascites secondary to cirrhosis.

Differential Diagnosis

Abdominal distention

Evaluation

Ascites appearance on ultrasound
Liver cirrhosis with ascites on CT

Management

Complications of cirrhosis

Pain management in cirrhotic patients

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[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%

See Also

External Links

References

  1. Heron M. Deaths: Leading Causes for 2013. Natl Vital Stat Rep 2016: 16;65(2):1-95.
  2. Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64
  3. 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.