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 login to view 13 more bullets portal hypertension login to view 5 more bullets 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) login to view 14 more bullets portal hypertension login to view 3 more bullets 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 login to view 1 more bullet ↑ 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 login to view 2 more bullets 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 login to view 1 more bullet alcohol and smoking cessation Medical antibiotic prophylaxis for spontaneous bacterial peritonitis indications login to view 1 more bullet diuretics indications login to view 1 more bullet modalities login to view 2 more bullets vaccinations indications login to view 1 more bullet modalities login to view 3 more bullets Surgical liver transplantation indications login to view 5 more bullets portal shunting indications login to view 1 more bullet Complications Hepatocellular carcinoma screening liver ultrasound and alpha-fetoprotein every 6 months Esophageal or gastric varices screening esophagogastroduodenoscopy (EGD) Spontaneous bacterial peritonitis