cirrhosis of liver portal hypertension hepatic enchepalopathy part-one 1 to 21 slides
Post on 25-Dec-2015
228 Views
Preview:
TRANSCRIPT
CIRRHOSIS OF LIVERPORTAL HYPERTENSION
HEPATIC ENCHEPALOPATHY
PART-ONE1 TO 21 slides
Definition of cirrhosis
Cirrhosis is derived from Greek word kirros=orange or tawny and osis=condition
-WHO definition :a diffuse process characterized by liver necrosis and fibrosis and conversion of normal liver architechture into structurally abnormal nodules that lack normal lobular organisation.
CAUSES OF LIVER CIRRHOSIS
-Infections:post hepatitic cirrhosis(B,D,C).-Toxins:Alcohol.-Cholestatic liver disease:PBC,PSC…-Autoimmune diseases:autoimmune hepatitis.-Vascular disorders: cardiac cirrhosis,Budd-Chiari
syndrome ,Veno occlusive disease-Metabolic and genetic :Wilson
disease ,hemochromatosis,alpha 1- antitrypsin deficiency
-Non alcoholic steato hepatitis(NASH). Cryptogenic.
Pathology of cirrhosis
-nodularity(regenerating nodules).-fibrosis(deposition of dense fibrous septa)-
fragmentation of sample.-abnormal liver architecture-hepatocyte
abnormalities:pleomorphism,dysplasia,hyperplasia
-Gross pathology:irregular surface ,yellowish colour,small,firm
CirrhosisCirrhosisNormalNormal
Nodules surrounded by fibrous tissueNodules surrounded by fibrous tissue
HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVER
HISTOLOGICAL IMAGE OF CIRRHOSIS
FibrosisFibrosis
Regenerative noduleRegenerative nodule
CompensatedcirrhosisCompensatedcirrhosis
DecompensatedcirrhosisDecompensatedcirrhosis DeathDeath
Chronic liver disease
Chronic liver disease
Natural History of Chronic Liver Disease
Development of complications:
Development of complications:
· Variceal hemorrhage
· Ascites· Encephalopathy· Jaundice
· Variceal hemorrhage
· Ascites· Encephalopathy· Jaundice
NATURAL HISTORY OF CHRONIC LIVER DISEASE
CLINICAL FEATURES• Hepatomegaly (although liver may also be small) • Jaundice • Ascites • Circulatory changes
– Spider telangiectasia, palmar erythema, cyanosis • Endocrine changes
– Loss of libido, hair loss – Men: gynaecomastia, testicular atrophy, impotence – Women: breast atrophy, irregular menses, amenorrhoea
• Haemorrhagic tendency – Bruises, purpura, epistaxis, menorrhagia
• Portal hypertension – Splenomegaly, collateral vessels, variceal bleeding, fetor hepaticus
• Hepatic (portosystemic) encephalopathy • Other features
– Pigmentation, digital clubbing
Liver insufficiencyLiver insufficiency
Variceal hemorrhageVariceal hemorrhage
Complications of Cirrhosis Result from Portal Hypertension or Liver InsufficiencyComplications of Cirrhosis Result from Portal Hypertension or Liver Insufficiency
CirrhosisCirrhosisAscitesAscites
EncephalopathyEncephalopathy
JaundiceJaundice
Portal hypertensionPortal hypertension Spontaneous
bacterial peritonitis
Spontaneous bacterial peritonitis
Hepatorenal syndromeHepatorenal syndrome
COMPLICATIONS OF CIRRHOSIS
Diagnosis of cirrhosis
• clinical+laboratory+radiologic+liver biopsy
In Whom Should We Suspect Cirrhosis?In Whom Should We Suspect Cirrhosis?
· Any patient with chronic liver disease· Chronic abnormal aminotransferases and/or
alkaline phosphatase
· Physical exam findings· Stigmata of chronic liver disease (muscle
wasting, vascular spiders, palmar erythema)· Palpable left lobe of the liver· Small liver span· Splenomegaly· Signs of decompensation (jaundice, ascites,
asterixis)
· Any patient with chronic liver disease· Chronic abnormal aminotransferases and/or
alkaline phosphatase
· Physical exam findings· Stigmata of chronic liver disease (muscle
wasting, vascular spiders, palmar erythema)· Palpable left lobe of the liver· Small liver span· Splenomegaly· Signs of decompensation (jaundice, ascites,
asterixis)
DIAGNOSIS OF CIRRHOSIS – CLINICAL FINDINGS
Laboratory· Liver insufficiency
· Low albumin (< 3.8 g/dL)· Prolonged prothrombin time (INR > 1.3)· High bilirubin (> 1.5 mg/dL)
· Portal hypertension· Low platelet count (< 175 x1000/ml)
· AST / ALT ratio > 1
Laboratory· Liver insufficiency
· Low albumin (< 3.8 g/dL)· Prolonged prothrombin time (INR > 1.3)· High bilirubin (> 1.5 mg/dL)
· Portal hypertension· Low platelet count (< 175 x1000/ml)
· AST / ALT ratio > 1
In Whom Should We Suspect Cirrhosis?In Whom Should We Suspect Cirrhosis?
DIAGNOSIS OF CIRRHOSIS – LABORATORY STUDIES
CT Scan in CirrhosisCT Scan in Cirrhosis
Liver with an irregular surfaceLiver with an irregular surface SplenomegalySplenomegalyCollateralsCollaterals
DIAGNOSIS OF CIRRHOSIS – CAT SCAN
NoNoYesYes
Diagnostic AlgorithmDiagnostic Algorithm
Patient with chronic liver disease and any of the following:· Variceal hemorrhage· Ascites· Hepatic encephalopathy
Patient with chronic liver disease and any of the following:· Variceal hemorrhage· Ascites· Hepatic encephalopathy
Liver biopsy not necessary for the diagnosis of cirrhosis
Liver biopsy not necessary for the diagnosis of cirrhosis
Physical findings:Enlarged left hepatic lobeSplenomegalyStigmata of chronic liver disease
Physical findings:Enlarged left hepatic lobeSplenomegalyStigmata of chronic liver disease
Laboratory findings:ThrombocytopeniaImpaired hepatic synthetic function
Laboratory findings:ThrombocytopeniaImpaired hepatic synthetic function
Radiological findings:· Small nodular liver· Intra-abdominal collaterals· Ascites· Splenomegaly· Colloid shift to spleen and/or bone marrow
Radiological findings:· Small nodular liver· Intra-abdominal collaterals· Ascites· Splenomegaly· Colloid shift to spleen and/or bone marrow
YesYes NoNo
YesYes NoNo
Liver biopsyLiver biopsy
DIAGNOSTIC ALGORITHM
Management of cirrhosis
-Specific treatment in some pre cirrhotic lesions: Wilson’s disease—Dpenicillamine,,hemochromatosis---phlebotomy,,antiviral drugs for chronic viral hepatitis
-in established cirrhosis---treatment of complications-screening for hepatocellular carcinoma-liver transplantation-maintenance of nutrition
CHILD-PUGH CLASSIFICATION OF PROGNOSIS IN CIRRHOSIS
Score 1 2 3Encephalopathy None Mild Marked
Bilirubin (mg/dl) < 2.0 2.0-3.0 > 3.0
Albumin (g/dl) > 3.5 3.0-3.5 < 3.0
Prothrombin time (seconds prolonged)
< 4 4-6 > 6
Ascites None Mild Marked
Add the individual scores:
< 7 = Child's A7-9 = Child's B> 9 = Child's C
MELD SCORE
• MELD = 3.8(SERUM BILIRUBIN –MG/DL)+11.2 IN INR + 9.6 IN SERUM CREATININE – MG/DL+ 6.4
PORTAL HYPERTENSION
Definition:it is an increase in portal venous pressure.
-normal portal pressure:5-10mmHg.-portal hypertension;>12mmHg-normal portal blood flow:1-1.5L/minute-- increased resistance to portal blood flow
+hyperdynamic circulation-----formation of porto systemic collaterals that diver blood to systemic circulation bypassing the liver
Mechanisms of Portal HypertensionMechanisms of Portal Hypertension
· Pressure (P) results from the interaction of resistance (R) and flow (F):
· Pressure (P) results from the interaction of resistance (R) and flow (F):
P = R x FP = R x F
· Portal hypertension can result from: · increase in resistance to portal flow
and/or · increase in portal venous inflow
· Portal hypertension can result from: · increase in resistance to portal flow
and/or · increase in portal venous inflow
MECHANISMS OF PORTAL HYPERTENSION
top related