Presentation on theme: "CIRRHOSIS OF LIVER PORTAL HYPERTENSION HEPATIC ENCHEPALOPATHY"— Presentation transcript:
1 CIRRHOSIS OF LIVER PORTAL HYPERTENSION HEPATIC ENCHEPALOPATHY PART-ONE1 TO 21 slides
2 Definition of cirrhosis Cirrhosis is derived from Greek word kirros=orange or tawny and osis=condition -WHO definition :a diffuse process characterized by liver necrosis and fibrosis and conversion of normal liver architechture into structurally abnormal nodules that lack normal lobular organisation.
5 Pathology of cirrhosis -nodularity(regenerating nodules). -fibrosis(deposition of dense fibrous septa)-fragmentation of sample. -abnormal liver architecture -hepatocyte abnormalities:pleomorphism,dysplasia,hyperplasia -Gross pathology:irregular surface ,yellowish colour,small,firm
6 HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVER CirrhosisSlide 8HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVERHistological images of two livers. On the left, a normal liver with conserved architecture. On the right, a cirrhotic liver with regenerative nodules surrounded by fibrous tissue (stained blue).Nodules surrounded by fibrous tissue
7 HISTOLOGICAL IMAGE OF CIRRHOSIS FibrosisRegenerative noduleSlide 9HISTOLOGICAL IMAGE OF CIRRHOSISHistological image of a cirrhotic liver showing regenerative nodules surrounded by fibrous tissue (stained blue).
8 NATURAL HISTORY OF CHRONIC LIVER DISEASE CompensatedcirrhosisDecompensatedcirrhosisDeathDevelopment of complications:Variceal hemorrhageAscitesEncephalopathyJaundiceSlide 14NATURAL HISTORY OF CHRONIC LIVER DISEASECirrhosis represents the end histological stage resulting from chronic liver injury of various etiologies. Initially, cirrhosis is compensated. The transition to a decompensated stage is marked by the development of variceal hemorrhage, ascites, hepatic encephalopathy and/or jaundice. Once decompensation occurs, the patient is at risk of death from liver disease.
9 CLINICAL FEATURES Hepatomegaly (although liver may also be small) JaundiceAscitesCirculatory changesSpider telangiectasia, palmar erythema, cyanosisEndocrine changesLoss of libido, hair lossMen: gynaecomastia, testicular atrophy, impotenceWomen: breast atrophy, irregular menses, amenorrhoeaHaemorrhagic tendencyBruises, purpura, epistaxis, menorrhagiaPortal hypertensionSplenomegaly, collateral vessels, variceal bleeding, fetor hepaticusHepatic (portosystemic) encephalopathyOther featuresPigmentation, digital clubbing
10 COMPLICATIONS OF CIRRHOSIS Complications of Cirrhosis Result from Portal Hypertension or Liver InsufficiencyVariceal hemorrhagePortal hypertensionSpontaneous bacterial peritonitisAscitesCirrhosisHepatorenal syndromeSlide 17COMPLICATIONS OF CIRRHOSISCirrhosis leads to two clinical syndromes: portal hypertension and liver insufficiency. Development of variceal hemorrhage and ascites are the direct consequence of portal hypertension, while jaundice occurs as a result of a compromised liver function. Encephalopathy is the result of both portal hypertension (portosystemic shunting) and liver dysfunction (decreased ammonia metabolism). Ascites in turn can become complicated by infection (spontaneous bacterial peritonitis) and by the development of a functional renal failure (hepatorenal syndrome).EncephalopathyLiver insufficiencyJaundice
11 Diagnosis of cirrhosis clinical+laboratory+radiologic+liver biopsy
12 DIAGNOSIS OF CIRRHOSIS – CLINICAL FINDINGS In Whom Should We Suspect Cirrhosis?Any patient with chronic liver diseaseChronic abnormal aminotransferases and/or alkaline phosphatasePhysical exam findingsStigmata of chronic liver disease (muscle wasting, vascular spiders, palmar erythema)Palpable left lobe of the liverSmall liver spanSplenomegalySigns of decompensation (jaundice, ascites, asterixis)Slide 19DIAGNOSIS OF CIRRHOSIS – CLINICAL FINDINGSCirrhosis should be investigated in any patient with chronic liver disease. Various physical signs suggest the presence of cirrhosis. In particular, a palpable left lobe with a small right lobe (on percussion) and splenomegaly are highly suggestive of cirrhosis. A recent review of several studies concludes that the listed physical findings, when present in chronic liver disease, confer a high specificity for cirrhosis. However the sensitivity is generally low and the absence of these physical signs does not exclude cirrhosis.De Bruyn G and Graviss EA, BMC Medical Informatics & Decision Making 2001; 1: 6
13 DIAGNOSIS OF CIRRHOSIS – LABORATORY STUDIES In Whom Should We Suspect Cirrhosis?LaboratoryLiver insufficiencyLow albumin (< 3.8 g/dL)Prolonged prothrombin time (INR > 1.3)High bilirubin (> 1.5 mg/dL)Portal hypertensionLow platelet count (< 175 x1000/ml)AST / ALT ratio > 1Slide 20DIAGNOSIS OF CIRRHOSIS – LABORATORY STUDIESTests that explore liver synthetic function are serum albumin and prothrombin time, while serum bilirubin investigates the ability of the liver to conjugate and excrete bilirubin. With liver dysfunction there is hypoalbuminemia,a prolonged prothrombin time and hyperbilirubinemia and the presence of either of these findings, in the presence of chronic liver disease, indicates the possibility of cirrhosis. However, an even earlier more sensitive finding suggestive of cirrhosis is a low platelet count that occurs as a result of portal hypertension and hypersplenism. An AST/ALT ratio >1 has also been identified as having a high specificity but a low sensitivity, therefore its absence cannot exclude cirrhosis.Poynard and Bedossa. J Viral Hepat. 1997; 4:199Dienstag JL, Hepatology 2002; 36 (Suppl 1): S152
15 DIAGNOSIS OF CIRRHOSIS – CAT SCAN CT Scan in CirrhosisSlide 23DIAGNOSIS OF CIRRHOSIS – CAT SCANThis slide shows typical computed tomography findings in compensated cirrhosis. The contour of the liver is irregular, there is obvious splenomegaly and the presence of collaterals indicates portal hypertension and secures the diagnosis of cirrhosis.Liver with an irregular surfaceCollateralsSplenomegaly
16 Liver biopsy Diagnostic Algorithm Patient with chronic liver disease and any of the following:Variceal hemorrhageAscitesHepatic encephalopathyPhysical findings:Enlarged left hepatic lobeSplenomegalyStigmata of chronic liver diseaseLaboratory findings:ThrombocytopeniaImpaired hepatic synthetic functionYesNoRadiological findings:Small nodular liverIntra-abdominal collateralsAscitesSplenomegalyColloid shift to spleen and/or bone marrowYesNoSlide 41DIAGNOSTIC ALGORITHMDiagnostic algorithm to investigate the presence of cirrhosis in patients with chronic liver disease.NoYesLiver biopsy not necessary for the diagnosis of cirrhosisLiver biopsy
17 Management of cirrhosis -Specific treatment in some pre cirrhotic lesions: Wilson’s disease—Dpenicillamine,,hemochromatosis---phlebotomy,,antiviral drugs for chronic viral hepatitis-in established cirrhosis---treatment of complications-screening for hepatocellular carcinoma-liver transplantation-maintenance of nutrition
18 CHILD-PUGH CLASSIFICATION OF PROGNOSIS IN CIRRHOSIS Score123EncephalopathyNoneMildMarkedBilirubin (mg/dl)< 2.0> 3.0Albumin (g/dl)> 3.5< 3.0Prothrombin time (seconds prolonged)< 44-6> 6AscitesAdd the individual scores:< 7 = Child's A 7-9 = Child's B > 9 = Child's C
19 MELD SCOREMELD = 3.8(SERUM BILIRUBIN –MG/DL)+11.2 IN INR IN SERUM CREATININE – MG/DL+ 6.4
20 PORTAL HYPERTENSIONDefinition:it is an increase in portal venous pressure. -normal portal pressure:5-10mmHg. -portal hypertension;>12mmHg -normal portal blood flow:1-1.5L/minute -- increased resistance to portal blood flow +hyperdynamic circulation-----formation of porto systemic collaterals that diver blood to systemic circulation bypassing the liver
21 MECHANISMS OF PORTAL HYPERTENSION Pressure (P) results from the interaction of resistance (R) and flow (F):P = R x FPortal hypertension can result from:increase in resistance to portal flow and/orincrease in portal venous inflowSlide 44MECHANISMS OF PORTAL HYPERTENSIONIn fluid mechanics, Ohm’s law states that pressure (P) is dependent upon flow (F) and resistance to flow (R). Therefore, portal hypertension can result from an increase in portal venous inflow, an increase in resistance to portal flow or an increase in both flow and resistance.