Cirrhosis

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Cirrhosis is a "liver disease in which the normal microcirculation, the gross vascular anatomy, and the hepatic architecture have been variably destroyed and altered with fibrous septa surrounding regenerated or regenerating parenchymal nodules."^[1]

Cause / etiology[edit]

The two most common causes, at least in women, may be alcoholism which causes alcoholic hepatitis and obesity with causes steatohepatitis.^[2] These two risks may have a "supra-additive interaction."^[3]

Diagnosis[edit]

Clinical prediction rules exist to help diagnosis cirrhosis.^[4]

• Pohl's Index is if the AST/ALT ratio ≥1 and platelet count ≤ 150,000/mm³ then cirrhosis is very likely.^[5]
• The Bonacini score is based on the ALT/AST ratio, platelet count, and INR.^[6]
  • A score of > 7 or 8 makes cirrhosis more likely.^[7]
  • A score of < 3 makes cirrhosis less likely.^[7]

In diagnosis of cirrhosis (Ishak scores, 5-6) in patients with hepatitis C, the aspartate aminotransferase to platelet ratio index (APRI) ratio > 1 suggests cirrhosis with accuracy of:^[8]

• Sensitivity = 79%
• Specificity = 78%

Complications[edit]

Clinical practice guidelines are available for the treatment of cirrhosis and its complications.^[9]

Ascites[edit]

For more information, see: Ascites.

Esophageal varices[edit]

A clinical prediction rule is available to help detect patients at risk of esophageal varices.^[10] For predicting clinically significant portal hypertension(hepatic venous pressure gradient ≥ 10 mmHg):^[10]

${\displaystyle Risk\ score\ =\ -0.193+(-0.359\times albumin)+(16.456\times INR)+(-0.0016\times ALT)}$

Risk score = -0.193 + (-0.359*albumin) + (16.456*INR) + (-0.0016*ALT)

At a cutoff value >0.06 the accuracy is:^[10]

• Sensitivity 93%
• Specificity 61%

For predicting esophagel varices:^[10]

${\displaystyle Risk\ score\ =\ -5.418+(-0.131\times albumin)+(1.949\times spider\ angiomas)+(-0.008\times ALT)}$

(spider angiomas = 1 if present and 0 if absent)

At a cutoff value >-1.02 the accuracy is:^[10]

• Sensitivity 93%
• Specificity 37%

Patients with a thrombocytopenia and a palpable spleen are more likely to have large esophageal varices.^[11][12] The cutoff for thrombocytopenia ranges from 40,000^[12] to 150,000^[11].

Treatment of bleeding[edit]

Transjugular intrahepatic portosystemic shunt may also add to endoscopic therapy for acute bleeding of esophageal varices.^[13]

Emergency portacaval shunt may be a better treatment than endoscopic sclerotherapy.^[14]

Prevention of bleeding[edit]

It is not clear that adding endoscopic band ligation to nadolol, an adrenergic_beta-antagonist, reduces bleeding.^[15]

Hepatic encephalopathy[edit]

For more information, see: Hepatic encephalopathy.

Hepatorenal syndrome[edit]

For more information, see: Hepatorenal syndrome.

Spontaneous bacterial peritonitis[edit]

For more information, see: Spontaneous bacterial peritonitis.

Spontaneous bacteremia[edit]

Spontaneous bacteremia may occur.^[16][17] Mong patients with Child-Pugh Score indicating class C, half of bacteremias may not have a definite focus.^[17]

Prognosis[edit]

MELD Score[edit]

For more information, see: MELD Score.

The MELD Score can help predict mortality. An online calculator is available.

Child-Pugh score[edit]

For more information, see: Child-Pugh Score.

The Child-Pugh Score can help predict mortality. An online calculator is available.

NAFLD fibrosis score[edit]

• http://nafldscore.com/

References[edit]