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  1. What findings are commonly seen on physical examination, laboratory studies, and imaging studies in patients with cirrhosis?

  2. How is the etiology of ascites determined and by sending what studies of ascitic fluid?

  3. What are common causes of renal failure in patients with cirrhosis?

  4. How is hepatorenal syndrome diagnosed and treated?

  5. How can hepatic encephalopathy present clinically, and what are the treatment options?

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Cirrhosis describes the end stage of chronic liver disease from any etiology. Histologically, injured and regenerating hepatocytes are surrounded by extracellular matrix or fibrosis, creating a nodular appearance to the liver parenchyma. A presumptive diagnosis of cirrhosis without histologic confirmation can often be made on clinical grounds alone. A palpable, enlarged left liver lobe with a small right lobe is highly suggestive of cirrhosis. Splenomegaly implies the presence of portal hypertension and cirrhosis. Cutaneous changes, such as spider angiomata and palmar erythema (Figure 159-1) and complications of end-stage liver disease, such as ascites and hepatic encephalopathy, are also strongly associated with underlying cirrhosis. While these physical findings have a high specificity for cirrhosis, their sensitivity is low.

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Figure 159-1
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(A) Spider angiomata. (Reproduced, with permission, from Wolff K, Goldsmith LA, Katz SI, et al. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York: McGraw-Hill; 2008. Fig. 151-9.) (B) Palmar erythema (Reproduced, with permission, from Wolff K, Goldsmith LA, Katz SI, et al. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York: McGraw-Hill; 2008. Fig. 151-8.)

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Laboratory tests that assess hepatic synthetic capacity such as prothrombin time (PT) or international normalized ratio (INR) and albumin concentration may be helpful in making the diagnosis of cirrhosis but can be confounded by variables such as nutritional status and comorbid conditions. Thrombocytopenia in a patient with chronic liver disease is the most sensitive and specific laboratory abnormality for cirrhosis. In patients with chronic hepatitis C infection, a ratio of AST to ALT that is greater than one has a high correlation with cirrhotic changes seen on liver biopsy. Cross-sectional imaging studies of the liver, including computed tomography, ultrasonography, and magnetic resonance imaging, are not sensitive for diagnosing cirrhosis, particularly in its early stages. However, they are reasonably accurate for detecting changes associated with late stages of cirrhosis, such as a small, nodular-appearing liver, splenomegaly, prominent collateral vessels in the portal circulation, and ascites.

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  • Thrombocytopenia in a patient with chronic liver disease is the most sensitive and specific laboratory abnormality for cirrhosis. Cross-sectional imaging studies of the liver, including computed tomography (CT), ultrasonography (US), and magnetic resonance imaging (MRI), are not sensitive for diagnosing cirrhosis, particularly in its early stages.
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Patients with cirrhosis may be asymptomatic (compensated) or have symptoms resulting from complications of end-stage liver ...

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