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G36 Gastroenterology
Liver Toronto Notes 2019
Figure 12. Progression of liver dysfunction based on liver function tests – the “W”
Cirrhosis
Definition
• liverdamagecharacterizedbydiffusedistortionofthebasicarchitectureandreplacementwithscar tissue and formation of regenerative nodules
• Biopsygoldstandardfordiagnosis
• Stage1cirrhosisiscompensatedandasymptomatic,canlastfor10-20yrwithalmostnormallife
expectancy
• Stage 2 cirrhosis is decompensation, typically development of ascites (most common), variceal bleeding,
encephalopathy, characteristically presents abruptly even though histologically the liver fibrosis is gradually progressive
Etiology
• fattyliver(alcoholicornon-alcoholicfattyliverdisease) • chronicviralhepatitis(B,B+D,C;notAorE)
• autoimmunehepatitis
• hemochromatosis
• primarybiliarycholangitis • chronichepaticcongestion
■ cardiac cirrhosis (chronic right heart failure, constrictive pericarditis)
■ hepatic vein thrombosis (Budd-Chiari)
• cryptogenic(i.e.noidentifiablecause,althoughmanyofthesepatientsmayrepresent“burnt-out
NASH”)
• rare:Wilson’sdisease,Gaucher’sdisease,α1-antitrypsindeficiency
Investigations
• definitivediagnosisishistologic(liverbiopsy) • othertestsmaybesuggestive
■ blood work: fall in platelet count <150 is the earliest finding, followed many years later with rise in INR, fall in albumin, rise in bilirubin, fall in glucose level (pre-terminal event)
■ FibroTest: combination of various clinical and biochemical markers that can predict degree of fibrosis
■ imaging
◆ U/S is the primary imaging modality but only finds advanced cirrhosis
◆ CT to look for varices, nodular liver texture, splenomegaly, ascites
◆ Transient Ultrasound Elastograhy (Fibroscan®): non-invasive tool using elastography (variable
availability) for measuring liver compliance
– rapidly replacing liver biopsy to determine extent of liver fibrosis and make the diagnosis of
cirrhosis
• gastroscopy:varicesorportalhypertensivegastropathy
Treatment
• treatunderlyingdisorder
• decreaseinsults(e.g.alcoholcessation,hepatotoxicdrugs,immunizeforHepAandBifnon-immune) • followpatientforcomplications(esophagealvarices,ascites,HCCdefinesstage2cirrhosis)
• prognosis:Child-PughScoreandMELDscore
• livertransplantationforend-stagediseaseifnoalcoholfor>6mo;useMELDscore
MELD-Na (Model for End Stage Liver Disease)
• Predicts 3 mo survival and used to stratify
patients on transplant list
• Based on creatinine, INR, total bilirubin,
and serum sodium concentration
Table 18. Child-Pugh Score and Interpretation
Classification 1
Serum bilirubin (μmol/L) <34 Serum albumin (g/L) >35 INR <1.7 Presence of ascites Absent Encephalopathy Absent
Interpretation
Points Class
5-6 A 7-9 B 10-15 C
2
34-51 28-35 1.7-2.3 Controllable Minimal
Life Expectancy
15-50 yr
Candidate for transplant 1-3 mo
3
>51
<28 >2.3 Refractory Severe
Perioperative Mortality
10% 30% 82%
Cirrhosis Complications
VARICES
Varices
Ascites/Anemia
Renal failure (hepatorenal syndrome) Infection
Coagulopathy Encephalopathy Sepsis
Score: 5-6 (Child’s A), 7-9 (Child’s B), 10-15 (Child’s C)
*Note: Child’s classification is rarely used for shunting (TIPS or other surgical shunts), but is still useful to quantitate the severity of cirrhosis
Platelets
Albumin
INR
Bilirubin