Snapshot A 50-year-old man presents to his primary care physician with yellowing skin and increased abdominal girth. He believes that he has gained weight and is worried about obesity. He also reports being concerned about increased breast size. He denies having a history of alcohol abuse, but when he is questioned further, he admits to drinking a bottle of vodka daily to cope with stressors in his life. On exam, he has spider angiomas on his abdomen, jaundice, and gynecomastia. Introduction Overview cirrhosis is a liver disease characterized by hepatic fibrosis, regenerative nodules, and dysfunction portal hypertension is a complication of cirrhosis, resulting in increased pressure in the portal venous system Epidemiology incidence very common cause of death risk factors alcoholic liver disease (most common) nonalcoholic steatohepatitis chronic viral hepatitis autoimmune hepatitis hepatocellular carcinoma primarily biliary cirrhosis α1-antitrypsin deficiency Wilson disease hemochromatosis Pathogenesis mechanism chronic liver damage results in regenerative nodules surrounded by bridging fibrosis abnormal wound healing with continued connective tissue deposition, resulting in fibrosis fibrosis mediated by stellate cells micronodular nodules < 3 mm following metabolic insult macronodular nodules > 3 mm following hepatic necrosis increased risk of hepatocellular carcinoma results in damage to hepatic vasculature fibrosis causes portal hypertension and shunting of portal and arterial blood impaired liver biosynthetic function decreased synthesis of albumin and other proteins leads to decreased plasma oncotic pressure portal hypertension increased portal hydrostatic pressure causes dilation of venous plexuses at sites of portal-systemic anastomoses (e.g., esophageal varices) regulatory response by the body (e.g., nitric oxide release) leads to splanchnic and systemic vasodilation, resulting in hypotension stimulates ADH release by the posterior pituitary low renal perfusion pressures cause activation of the renin-angiotensin-aldosterone system Prognosis Model for End-Stage Liver Disease (MELD) score predicts 3-month mortality in patients with cirrhosis creatinine bilirubin INR Presentation Symptoms common symptoms fatigue weakness weight loss loss of appetite pruritus upper gastrointestinal bleeding Physical exam inspection mental status changes signs of liver disease (BAD JPEGS) Bleeding ↑ prothrombin time Asterix “flapping” tremor Dupuytren contracture Jaundice ↓ excretion of bilirubin Palmar erythema Encephalopathy ↓ excretion of ammonia Gynecomastia ↓ degradation of estrogen Spider angiomata ↓ degradation of estrogen portal hypertension hepatosplenomegaly caput medusa ascites Imaging Computed tomography (CT) of abdomen indications other imaging studies are inconclusive patients often undergo CT of the abdomen during workup to exclude other pathologies findings nodularity hypertrophy ascites Liver ultrasound indications all patients findings fibrosis nodularity increased echogenicity atrophy or hypertrophy of liver lobes Transient elastography indications measures liver stiffness all patients findings hepatic fibrosis and increased stiffness Studies Serum labs multiple severity scores exist for cirrhosis but often include ↑ liver enzymes ↑ prothrombin time treat with fresh frozen plasma or factor replacement ↑ direct bilirubin ↓ platelets creatinine determining etiology hepatitis B and C serology alpha-1 antitrypsin levels antinuclear antibody anti-smooth muscle titers anti-mitochondrial antibody ferritin transferrin saturation levels 24-hour copper level in the urine ceruloplasmin hemochromatosis genetic testing Invasive studies liver biopsy indications patients who cannot undergo transient elastography clinical presentation is not consistent with a diagnosis Differential Acute viral hepatitis key distinguishing factor acute onset of symptoms with viral prodrome, nausea, vomiting, and abdominal pain lacks findings of chronic liver disease Treatment Management approach treat underlying cause if possible Lifestyle diet with restricted sodium indications all patients with ascites alcohol and smoking cessation Medical antibiotic prophylaxis for spontaneous bacterial peritonitis indications cirrhosis and gastrointestinal bleeding or ascites diuretics indications patients with ascites modalities furosemide spironolactone vaccinations indications all patients modalities hepatitis A hepatitis B 23-valent pneumococcal vaccine Surgical liver transplantation indications refractory liver cirrhosis major complications ascites variceal bleeding hepatic encephalopathy portal shunting indications portal hypertension Complications Hepatocellular carcinoma screening liver ultrasound and alpha-fetoprotein every 6 months Esophageal or gastric varices screening esophagogastroduodenoscopy (EGD) Spontaneous bacterial peritonitis