Snapshot A 65-year-old male with a long history of alcohol abuse presents to an emergency room with a painful hemorrhoid. You note severe ascites on exam. Introduction Irreversible liver damage resulting in fibrosis hepatocytes regenerate forming nodules but have abnormal architecture there are 2 types of nodules micronodular nodules < 3 mm, uniform size follows metabolic insult macronodular nodules > 3 mm, varied size hepatic necrosis ↑ risk of hepatocellular carcinoma nodules increase vessel pressure in the sinusoids results in congestion of the portal vein Causes similar etiologies to hepatitis alcohol (micronodular) most common cause in the United States. metabolic (micronodular) Wilson's hemochromatosis chronic viral hepatitis (macronodular) results in a specific "post-necrotic" cirrhosis drug-induced (macronodular) autoimmune primary biliary cirrhosis autoimmune hepatitis Both lead to an increased risk of hepatocellular carcinoma Presentation Physical exam caused by two main disease processes hepatic failure palmar erythema Dupuytren's contracture encephalopathy ↓ excretion of ammonia worse in alkalemic states NH3 favored over NH4+ jaundice ↓ excretion of billirubin pitting ankle edema ↓ synthesis synthesis of albumin gynecomastia/spider angiomas/female hair distribution ↓ degradation of estrogens bleeding (↑ PT) ↓ synthesis of coagulation factors asterix "flapping" tremor portal hypertension hepatosplenomegaly splenomegaly is secondary to portal hypertension caput medusae ascites also due to hypoalbuminemia, secondary hyperaldosteronism Evaluation Elevated AST and ALT AST:ALT > 2 suggests alcoholic hepatitis other liver pathologies have ALT > AST inversed because AST is found in the mitochondria and EtOH is a mitochondiral toxin Absolute neutrophilic leukocytosis seen in hepatitis but not fatty change Fasting hypoglycemia Increased anion gap metabolic acidosis Hypertriglyceridemia Hyperuricemia Thrombocytopenia Increased γ-gluamyltransferase secondary to EtOH induced hyperplasia of the smooth ER Treatment Surgical liver transplant portal shunting portacaval portal → hepatic vein mesocaval SMV → vena cava splenorenal splenic vein→ renal vein transjugular intrahepatic portosystemic portal → hepatic vein Prognosis, Prevention, and Complications Complications of portal hypertension esophageal varices may rupture resulting in massive hematemesis hemorrhoids spontaneous bacterial peritonitis