Cirrhosis: Difference between revisions
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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."<ref name="title">{{cite web |url=http://www.nlm.nih.gov/cgi/mesh/2008/MB_cgi?mode=&term=Liver+Cirrhosis |title=Liver cirrhosis |accessdate=2008-01-07 |author=Anonymous |authorlink= |coauthors= |date= |format= |work= |publisher=National Library of Medicine |pages= |language= |archiveurl= |archivedate= |quote=}}</ref> | '''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."<ref name="title">{{cite web |url=http://www.nlm.nih.gov/cgi/mesh/2008/MB_cgi?mode=&term=Liver+Cirrhosis |title=Liver cirrhosis |accessdate=2008-01-07 |author=Anonymous |authorlink= |coauthors= |date= |format= |work= |publisher=National Library of Medicine |pages= |language= |archiveurl= |archivedate= |quote=}}</ref> | ||
==Cause / etiology== | |||
The two most common causes, at least in women, may be [[alcoholism]] which causes [[alcoholic hepatitis]] and [[obesity]] with causes [[steatohepatitis]].<ref name="pmid20223875">{{cite journal| author=Liu B, Balkwill A, Reeves G, Beral V, on behalf of the Million Women Study Collaborators.| title=Body mass index and risk of liver cirrhosis in middle aged UK women: prospective study. | journal=BMJ | year= 2010 | volume= 340 | issue= | pages= c912 | pmid=20223875 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=20223875 | doi=10.1136/bmj.c912 }} </ref> These two risks may have a "supra-additive interaction."<ref name="pmid20223873">{{cite journal| author=Hart CL, Morrison DS, Batty GD, Mitchell RJ, Davey Smith G| title=Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies. | journal=BMJ | year= 2010 | volume= 340 | issue= | pages= c1240 | pmid=20223873 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=20223873 | doi=10.1136/bmj.c1240 }} </ref> | |||
==Diagnosis== | ==Diagnosis== | ||
[[Clinical prediction rule]]s exist to help diagnosis cirrhosis.<ref name="pmid16918883">{{cite journal| author=Borroni G, Ceriani R, Cazzaniga M, Tommasini M, Roncalli M, Maltempo C et al.| title=Comparison of simple tests for the non-invasive diagnosis of clinically silent cirrhosis in chronic hepatitis C. | journal=Aliment Pharmacol Ther | year= 2006 | volume= 24 | issue= 5 | pages= 797-804 | pmid=16918883 | [[Clinical prediction rule]]s exist to help diagnosis cirrhosis.<ref name="pmid22357834">{{cite journal| author=Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL et al.| title=Does this patient with liver disease have cirrhosis? | journal=JAMA | year= 2012 | volume= 307 | issue= 8 | pages= 832-42 | pmid=22357834 | doi=10.1001/jama.2012.186 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22357834 }} </ref> | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16918883 | doi=10.1111/j.1365-2036.2006.03034.x }} < | * Pohl's Index is if the AST/ALT ratio ≥1 and platelet count ≤ 150,000/mm<sup>3</sup> then cirrhosis is very likely.<ref name="pmid16918883">{{cite journal| author=Borroni G, Ceriani R, Cazzaniga M, Tommasini M, Roncalli M, Maltempo C et al.| title=Comparison of simple tests for the non-invasive diagnosis of clinically silent cirrhosis in chronic hepatitis C. | journal=Aliment Pharmacol Ther | year= 2006 | volume= 24 | issue= 5 | pages= 797-804 | pmid=16918883 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16918883 | doi=10.1111/j.1365-2036.2006.03034.x }}</ref> | |||
* The [http://jama.ama-assn.org/content/307/8/832/F3.expansion.html Bonacini score] is based on the ALT/AST ratio, platelet count, and INR.<ref name="pmid16437635">{{cite journal| author=Colli A, Colucci A, Paggi S, Fraquelli M, Massironi S, Andreoletti M et al.| title=Accuracy of a predictive model for severe hepatic fibrosis or cirrhosis in chronic hepatitis C. | journal=World J Gastroenterol | year= 2005 | volume= 11 | issue= 46 | pages= 7318-22 | pmid=16437635 | doi= | pmc= | url= }} </ref> | |||
** A score of > 7 or 8 makes cirrhosis more likely.<ref name="RCE">[http://jama.ama-assn.org/content/307/8/832.full Does this patient have cirrhosis?] JAMA 2012</ref> | |||
** A score of < 3 makes cirrhosis less likely.<ref name="RCE">[http://jama.ama-assn.org/content/307/8/832.full Does this patient have cirrhosis?] JAMA 2012</ref> | |||
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:<ref name="pmid23142332">{{cite journal| author=Gara N, Zhao X, Kleiner DE, Liang TJ, Hoofnagle JH, Ghany MG| title=Discordance among transient elastography, aspartate aminotransferase to platelet ratio index, and histologic assessments of liver fibrosis in patients with chronic hepatitis C. | journal=Clin Gastroenterol Hepatol | year= 2013 | volume= 11 | issue= 3 | pages= 303-308.e1 | pmid=23142332 | doi=10.1016/j.cgh.2012.10.044 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23142332 }} </ref> | |||
* Sensitivity = 79% | |||
* Specificity = 78% | |||
==Complications== | ==Complications== | ||
| Line 14: | Line 29: | ||
===Esophageal varices=== | ===Esophageal varices=== | ||
A clinical prediction rule is available to help detect patients at risk.<ref name="pmid18477345">{{cite journal |author=Berzigotti A, Gilabert R, Abraldes JG, ''et al'' |title=Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis |journal=Am. J. Gastroenterol. |volume=103 |issue=5 |pages=1159–67 |year=2008 |month=May |pmid=18477345 |doi=10.1111/j.1572-0241.2008.01826.x |url= |issn=}}</ref> | A clinical prediction rule is available to help detect patients at risk of [[esophageal varices]].<ref name="pmid18477345">{{cite journal |author=Berzigotti A, Gilabert R, Abraldes JG, ''et al'' |title=Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis |journal=Am. J. Gastroenterol. |volume=103 |issue=5 |pages=1159–67 |year=2008 |month=May |pmid=18477345 |doi=10.1111/j.1572-0241.2008.01826.x |url= |issn=}}</ref> | ||
For predicting clinically significant portal hypertension(hepatic venous pressure gradient ≥ 10 mmHg):<ref name="pmid18477345"/> | For predicting clinically significant portal hypertension(hepatic venous pressure gradient ≥ 10 mmHg):<ref name="pmid18477345"/> | ||
:<math>Risk\ score\ =\ -0.193 + (-0.359\times albumin) + (16.456\times INR) + (-0.0016\times ALT) + (-0. | :<math>Risk\ score\ =\ -0.193 + (-0.359\times albumin) + (16.456\times INR) + (-0.0016\times ALT)</math> | ||
:Risk score = -0.193 + (-0.359*[[albumin]]) + (16.456*[[INR]]) + (-0.0016*ALT) | |||
At a cutoff value >0.06 the accuracy is:<ref name="pmid18477345"/> | At a cutoff value >0.06 the accuracy is:<ref name="pmid18477345"/> | ||
* [[Sensitivity and specificity|Sensitivity]] 93% | * [[Sensitivity and specificity|Sensitivity]] 93% | ||
| Line 22: | Line 39: | ||
For predicting esophagel varices:<ref name="pmid18477345"/> | For predicting esophagel varices:<ref name="pmid18477345"/> | ||
:<math>Risk\ score\ =\ -5.418 + (-0.131\times albumin) + (1.949\times spider\ angiomas) + (-0. | :<math>Risk\ score\ =\ -5.418 + (-0.131\times albumin) + (1.949\times spider\ angiomas) + (-0.008\times ALT)</math> | ||
:(spider angiomas = 1 if present and 0 if absent) | :(spider angiomas = 1 if present and 0 if absent) | ||
At a cutoff value >-1.02 the accuracy is:<ref name="pmid18477345"/> | At a cutoff value >-1.02 the accuracy is:<ref name="pmid18477345"/> | ||
| Line 28: | Line 45: | ||
* [[Sensitivity and specificity|Specificity]] 37% | * [[Sensitivity and specificity|Specificity]] 37% | ||
Patients with a | Patients with a thrombocytopenia and a [[palpation|palpable]] spleen are more likely to have large esophageal varices.<ref name="pmid20065573">{{cite journal| author=Sarangapani A, Shanmugam C, Kalyanasundaram M, Rangachari B, Thangavelu P, Subbarayan JK| title=Noninvasive prediction of large esophageal varices in chronic liver disease patients. | journal=Saudi J Gastroenterol | year= 2010 Jan-Mar | volume= 16 | issue= 1 | pages= 38-42 | pmid=20065573 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=20065573 | doi=10.4103/1319-3767.58767 }}</ref><ref name="pmid17914969">{{cite journal |author=Sharma SK, Aggarwal R |title=Prediction of large esophageal varices in patients with cirrhosis of the liver using clinical, laboratory and imaging parameters |journal=J. Gastroenterol. Hepatol. |volume=22 |issue=11 |pages=1909–15 |year=2007 |pmid=17914969 |doi=10.1111/j.1440-1746.2006.04501.x}}</ref> The cutoff for thrombocytopenia ranges from 40,000<ref name="pmid17914969"/> to 150,000<ref name="pmid20065573"/>. | |||
Emergency [[portacaval shunt]] | ====Treatment of bleeding==== | ||
[[Transjugular intrahepatic portosystemic shunt]] may also add to endoscopic therapy for acute bleeding of [[esophageal varices]].<ref>{{Cite journal | doi = 10.1056/NEJMoa0910102 | volume = 362 | issue = 25 | pages = 2370-2379 | last = Garcia-Pagan | first = Juan Carlos | coauthors = Karel Caca, Christophe Bureau, Wim Laleman, Beate Appenrodt, Angelo Luca, Juan G. Abraldes, Frederik Nevens, Jean Pierre Vinel, Joachim Mossner, Jaime Bosch, the Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group | title = Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding | journal = N Engl J Med | accessdate = 2010-06-25 | date = 2010-06-24 | url = http://content.nejm.org/cgi/content/abstract/362/25/2370 }}</ref> | |||
Emergency [[portacaval shunt]] may be a better treatment than endoscopic sclerotherapy.<ref name="pmid19651060">{{cite journal |author=Orloff MJ, Isenberg JI, Wheeler HO, ''et al.'' |title=Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis |journal=J. Am. Coll. Surg. |volume=209 |issue=1 |pages=25–40 |year=2009 |month=July |pmid=19651060 |doi=10.1016/j.jamcollsurg.2009.02.059 |url=http://linkinghub.elsevier.com/retrieve/pii/S1072-7515(09)00278-6 |issn=}}</ref> | |||
====Prevention of bleeding==== | |||
It is not clear that adding endoscopic band ligation to [[nadolol]], an [[adrenergic_beta-antagonist]], reduces bleeding.<ref name="pmid20578138">{{cite journal| author=Lo GH, Chen WC, Wang HM, Lee CC| title=Controlled trial of ligation plus nadolol versus nadolol alone for the prevention of first variceal bleeding. | journal=Hepatology | year= 2010 | volume= 52 | issue= 1 | pages= 230-7 | pmid=20578138 | doi=10.1002/hep.23617 }} </ref> | |||
===Hepatic encephalopathy=== | ===Hepatic encephalopathy=== | ||
| Line 52: | Line 76: | ||
{{main|Child-Pugh Score}} | {{main|Child-Pugh Score}} | ||
The [[Child-Pugh Score]] can help predict mortality. An [http://depts.washington.edu/uwhep/calculations/childspugh.htm online calculator] is available. | The [[Child-Pugh Score]] can help predict mortality. An [http://depts.washington.edu/uwhep/calculations/childspugh.htm online calculator] is available. | ||
===NAFLD fibrosis score=== | |||
* http://nafldscore.com/ | |||
==References== | ==References== | ||
<references/> | <references/> | ||
Latest revision as of 12:08, 12 May 2015
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
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
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]
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
Clinical practice guidelines are available for the treatment of cirrhosis and its complications.[9]
Ascites
Esophageal varices
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]
At a cutoff value >0.06 the accuracy is:[10]
- Sensitivity 93%
- Specificity 61%
For predicting esophagel varices:[10]
- (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
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
It is not clear that adding endoscopic band ligation to nadolol, an adrenergic_beta-antagonist, reduces bleeding.[15]
Hepatic encephalopathy
Hepatorenal syndrome
Spontaneous bacterial peritonitis
Spontaneous bacteremia
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
MELD Score
The MELD Score can help predict mortality. An online calculator is available.
Child-Pugh score
The Child-Pugh Score can help predict mortality. An online calculator is available.
NAFLD fibrosis score
References
- ↑ Anonymous. Liver cirrhosis. National Library of Medicine. Retrieved on 2008-01-07.
- ↑ Liu B, Balkwill A, Reeves G, Beral V, on behalf of the Million Women Study Collaborators. (2010). "Body mass index and risk of liver cirrhosis in middle aged UK women: prospective study.". BMJ 340: c912. DOI:10.1136/bmj.c912. PMID 20223875. Research Blogging.
- ↑ Hart CL, Morrison DS, Batty GD, Mitchell RJ, Davey Smith G (2010). "Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies.". BMJ 340: c1240. DOI:10.1136/bmj.c1240. PMID 20223873. Research Blogging.
- ↑ Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL et al. (2012). "Does this patient with liver disease have cirrhosis?". JAMA 307 (8): 832-42. DOI:10.1001/jama.2012.186. PMID 22357834. Research Blogging.
- ↑ Borroni G, Ceriani R, Cazzaniga M, Tommasini M, Roncalli M, Maltempo C et al. (2006). "Comparison of simple tests for the non-invasive diagnosis of clinically silent cirrhosis in chronic hepatitis C.". Aliment Pharmacol Ther 24 (5): 797-804. DOI:10.1111/j.1365-2036.2006.03034.x. PMID 16918883. Research Blogging.
- ↑ Colli A, Colucci A, Paggi S, Fraquelli M, Massironi S, Andreoletti M et al. (2005). "Accuracy of a predictive model for severe hepatic fibrosis or cirrhosis in chronic hepatitis C.". World J Gastroenterol 11 (46): 7318-22. PMID 16437635. [e]
- ↑ 7.0 7.1 Does this patient have cirrhosis? JAMA 2012
- ↑ Gara N, Zhao X, Kleiner DE, Liang TJ, Hoofnagle JH, Ghany MG (2013). "Discordance among transient elastography, aspartate aminotransferase to platelet ratio index, and histologic assessments of liver fibrosis in patients with chronic hepatitis C.". Clin Gastroenterol Hepatol 11 (3): 303-308.e1. DOI:10.1016/j.cgh.2012.10.044. PMID 23142332. Research Blogging.
- ↑ Garcia-Tsao G, Lim JK, Lim J (2009). "Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program.". Am J Gastroenterol 104 (7): 1802-29. DOI:10.1038/ajg.2009.191. PMID 19455106. Research Blogging.
- ↑ 10.0 10.1 10.2 10.3 10.4 Berzigotti A, Gilabert R, Abraldes JG, et al (May 2008). "Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis". Am. J. Gastroenterol. 103 (5): 1159–67. DOI:10.1111/j.1572-0241.2008.01826.x. PMID 18477345. Research Blogging.
- ↑ 11.0 11.1 Sarangapani A, Shanmugam C, Kalyanasundaram M, Rangachari B, Thangavelu P, Subbarayan JK (2010 Jan-Mar). "Noninvasive prediction of large esophageal varices in chronic liver disease patients.". Saudi J Gastroenterol 16 (1): 38-42. DOI:10.4103/1319-3767.58767. PMID 20065573. Research Blogging.
- ↑ 12.0 12.1 Sharma SK, Aggarwal R (2007). "Prediction of large esophageal varices in patients with cirrhosis of the liver using clinical, laboratory and imaging parameters". J. Gastroenterol. Hepatol. 22 (11): 1909–15. DOI:10.1111/j.1440-1746.2006.04501.x. PMID 17914969. Research Blogging.
- ↑ Garcia-Pagan, Juan Carlos; Karel Caca, Christophe Bureau, Wim Laleman, Beate Appenrodt, Angelo Luca, Juan G. Abraldes, Frederik Nevens, Jean Pierre Vinel, Joachim Mossner, Jaime Bosch, the Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group (2010-06-24). "Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding". N Engl J Med 362 (25): 2370-2379. DOI:10.1056/NEJMoa0910102. Retrieved on 2010-06-25. Research Blogging.
- ↑ Orloff MJ, Isenberg JI, Wheeler HO, et al. (July 2009). "Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis". J. Am. Coll. Surg. 209 (1): 25–40. DOI:10.1016/j.jamcollsurg.2009.02.059. PMID 19651060. Research Blogging.
- ↑ Lo GH, Chen WC, Wang HM, Lee CC (2010). "Controlled trial of ligation plus nadolol versus nadolol alone for the prevention of first variceal bleeding.". Hepatology 52 (1): 230-7. DOI:10.1002/hep.23617. PMID 20578138. Research Blogging.
- ↑ Ortiz J, Vila MC, Soriano G, et al (April 1999). "Infections caused by Escherichia coli resistant to norfloxacin in hospitalized cirrhotic patients". Hepatology 29 (4): 1064–9. DOI:10.1002/hep.510290406. PMID 10094947. Research Blogging.
- ↑ 17.0 17.1 Monte Secades R, Casariego Vales E, Mateos Colino A, et al (November 1999). "[Clinical profile and prognosis of bacteremia in patients with cirrhosis based on the Child-Pugh classification]" (in Spanish; Castilian). Rev Clin Esp 199 (11): 716–21. PMID 10638235. [e]