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Liver Cirrhosis S. Diana Garcia

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1 Liver Cirrhosis S. Diana Garcia
The word "cirrhosis" derives from Greek κίρῥος, meaning tawny (the orange-yellow colour of the diseased liver).

2 What is Liver Cirrhosis?
Cirrhosis (pronounced sih-ROW-sis) is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue, and regenerative nodules leading to loss of liver function. Cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. Scar tissue replaces healthy liver tissue, partially blocking the flow of blood through the liver. It is caused by accumulation in the bloodstream of toxic substances that are normally removed by the liver. Def: regenerative nodules (lumps that occur as a result of a process in which damaged tissue is regenerated),

3 Liver Cirrhosis Impairment
Scarring also impairs the liver’s ability to: control infections remove bacteria and toxins from the blood process nutrients, hormones, and drugs make proteins that regulate blood clotting produce bile to help absorb fats—including cholesterol—and fat-soluble vitamins A healthy liver is able to regenerate most of its own cells when they become damaged. With end-stage cirrhosis, the liver can no longer effectively replace damaged cells. A healthy liver is necessary for survival. As cirrhosis can be caused by many different entities which injure the liver in different ways, different cause-specific patterns of cirrhosis, and other cause-specific abnormalities can be seen in cirrhosis. For example, in chronic hepatitis B, there is infiltration of the liver parenchyma with lymphocytes;[13] in cardiac cirrhosis there are erythrocytes and a greater amount of fibrosis in the tissue surrounding the hepatic veins;[14] in primary biliary cirrhosis, there is fibrosis around the bile duct, the presence of granulomas and pooling of bile;[15] and in alcoholic cirrhosis, there is infiltration of the liver with neutrophils.[13

4 What causes cirrhosis? Alcohol-related liver disease
Chronic hepatitis C Chronic hepatitis B and D Nonalcoholic fatty liver disease (NAFLD) Autoimmune hepatitis Inherited diseases Drugs, toxins, and infections In the United States, heavy alcohol consumption and chronic hepatitis C have been the most common causes of cirrhosis. Obesity is becoming a common cause of cirrhosis, either as the sole cause or in combination with alcohol, hepatitis C, or both. Many people with cirrhosis have more than one cause of liver damage. Cirrhosis is not caused by trauma to the liver or other acute, or short-term, causes of damage. Usually years of chronic injury are required to cause cirrhosis. Some cases are idiopathic

5 What are the symptoms of cirrhosis?
Many people with cirrhosis have no symptoms in the early stages of the disease. However, as the disease progresses, a person may experience the following symptoms: weakness fatigue loss of appetite nausea vomiting weight loss abdominal pain and bloating when fluid accumulates in the abdomen itching spiderlike blood vessels on the skin

6 What are the complications of cirrhosis?
Edema and ascites. Bruising and bleeding Portal hypertension Esophageal varices and gastropathy Splenomegaly Jaundice Gallstones Sensitivity to medications Hepatic encephalopathy Insulin resistance and type 2 diabetes Liver cancer Other problems As liver function deteriorates, one or more complications may develop. In some people, complications may be the first signs of the disease. Spider angiomata or spider nevi. Vascular lesions consisting of a central arteriole surrounded by many smaller vessels due to an increase in estradiol. These occur in about 1/3 of cases.[5] Palmar erythema. Exaggerations of normal speckled mottling of the palm, due to altered sex hormone metabolism. Nail changes. Muehrcke's lines - paired horizontal bands separated by normal color due to hypoalbuminemia (inadequate production of albumin). Terry's nails - proximal two-thirds of the nail plate appears white with distal one-third red, also due to hypoalbuminemia Clubbing - angle between the nail plate and proximal nail fold > 180 degrees Hypertrophic osteoarthropathy. Chronic proliferative periostitis of the long bones that can cause considerable pain. Dupuytren's contracture. Thickening and shortening of palmar fascia that leads to flexion deformities of the fingers. Thought to be due to fibroblastic proliferation and disorderly collagen deposition. It is relatively common (33% of patients). Gynecomastia. Benign proliferation of glandular tissue of male breasts presenting with a rubbery or firm mass extending concentrically from the nipples. This is due to increased estradiol and can occur in up to 66% of patients. Hypogonadism. Manifested as impotence, infertility, loss of sexual drive, and testicular atrophy due to primary gonadal injury or suppression of hypothalamic or pituitary function. Liver size. Can be enlarged, normal, or shrunken. Splenomegaly (increase in size of the spleen). Due to congestion of the red pulp as a result of portal hypertension. Ascites. Accumulation of fluid in the peritoneal cavity giving rise to flank dullness (needs about 1500 mL to detect flank dullness). It may be associated with hydrocele and penile flomation (swelling of the penile shaft)[citation needed] in men. Caput medusa. In portal hypertension, the umbilical vein may open. Blood from the portal venous system may be shunted through the periumbilical veins into the umbilical vein and ultimately to the abdominal wall veins, manifesting as caput medusa. Cruveilhier-Baumgarten murmur. Venous hum heard in epigastric region (on examination by stethoscope) due to collateral connections between portal system and the remnant of the umbilical vein in portal hypertension. Fetor hepaticus. Musty odor in breath due to increased dimethyl sulfide. Jaundice. Yellow discoloring of the skin, eye, and mucus membranes due to increased bilirubin (at least 2–3 mg/dL or 30 mmol/L). Urine may also appear dark. Asterixis. Bilateral asynchronous flapping of outstretched, dorsiflexed hands seen in patients with hepatic encephalopathy. Other. Weakness, fatigue, anorexia, weight loss. ComplicationsHepatic encephalopathy (also known as portosystemic encephalopathy) is the occurrence of confusion, altered level of consciousness and coma as a result of liver failure. In the advanced stages it is called hepatic coma or coma hepaticum. It may ultimately lead to death.[1]

7 How is cirrhosis diagnosed?
The diagnosis of cirrhosis is usually based on the presence of a risk factor for cirrhosis, such as alcohol use or obesity, and is confirmed by physical examination, blood tests, and imaging. To view the liver for signs of enlargement, reduced blood flow, or ascites, the doctor may order a computerized tomography (CT) scan, ultrasound, magnetic resonance imaging (MRI), or liver scan. The doctor may look at the liver directly by inserting a laparoscope into the abdomen. A liver biopsy can confirm the diagnosis of cirrhosis but is not always necessary. A biopsy is usually done if the result might have an impact on treatment. The biopsy is performed with a needle inserted between the ribs or into a vein in the neck. The doctor will ask : medical history and symptoms and perform a thorough physical examination to observe for clinical signs of the disease. For example, on abdominal examination, the liver may feel hard or enlarged with signs of ascites. The doctor will order blood tests that may be helpful in evaluating the liver and increasing the suspicion of cirrhosis. A laparoscope is an instrument with a camera that relays pictures to a computer screen.

8 How is the severity of cirrhosis measured?
The model for end-stage liver disease (MELD) score measures the severity of cirrhosis. The MELD score was developed to predict the 90-day survival of people with advanced cirrhosis. The MELD score is based on three blood tests: international normalized ratio (INR)—tests the clotting tendency of blood bilirubin—tests the amount of bile pigment in the blood creatinine—tests kidney function MELD scores usually range between 6 and 40, with a score of 6 indicating the best likelihood of 90-day survival.

9 How is cirrhosis treated?
Treatment for cirrhosis depends on the cause of the disease and whether complications are present. The goals of treatment are to slow the progression of scar tissue in the liver and prevent or treat the complications of the disease. Hospitalization may be necessary for cirrhosis with complications. Hospital Inpatient Care Number of discharges with chronic liver disease or cirrhosis as the first-listed diagnosis: 112,000 (reported in 2005) Mortality Number of deaths: 27,555 Deaths per 100,000 population: 9.2 Source: Deaths: Final Data for 2006, tables 10, 11

10 When is a liver transplant indicated for cirrhosis?
Liver transplantation is a major operation in which the diseased liver is removed and replaced with a healthy one from an organ donor. The number of people who need a liver transplant far exceeds the number of available organs. A person needing a transplant must go through a complicated evaluation process before being added to a long transplant waiting list. Generally, organs are given to people with the best chance of living the longest after a transplant. Survival after a transplant requires intensive follow-up and cooperation on the part of the patient and caregiver. A liver transplant is considered when complications cannot be controlled by treatment. A team of health professionals determines the risks and benefits of the procedure for each patient. Survival rates have improved over the past several years because of drugs that suppress the immune system and keep it from attacking and damaging the new liver.

11 References National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (viewed on ) Faststats : Chronic Liver Disease or Cirrhosis: Source: National Hospital Discharge Survey:  2005 Annual Summary with Detailed Diagnosis and Procedure Data, table 45 (see ICD9-CM code 571) (viewed on ) MayoClinic : Cirrhosis (viewed on )

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