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For further information, see CMDT Part 16-11: Cirrhosis

Key Features

Essentials of Diagnosis

  • End result of injury that leads to both fibrosis and regenerating nodules

  • May be reversible if cause is removed

  • The clinical features result from hepatic cell dysfunction, portosystemic shunting, and portal hypertension

General Considerations

  • The most common histologic classification of cirrhosis is micronodular, macronodular, and mixed forms

  • Each form may be seen at different stages of the disease

  • Risk factors

    • Chronic viral hepatitis

    • Alcohol

    • Drug toxicity

    • Autoimmune and metabolic liver diseases, including nonalcoholic fatty liver disease

    • Miscellaneous disorders

  • Gluten enteropathy appears to be associated with an increased risk of cirrhosis

  • Many patients have more than one risk factor (eg, chronic hepatitis and alcohol use)

  • Three clinical stages

    • Compensated

    • Compensated with varices

    • Decompensated (ascites, variceal bleeding, encephalopathy, or jaundice)

  • Acute-on-chronic liver failure

    • Should be diagnosed in a patient with chronic cirrhosis and acute decompensation, which is defined as

      • New or worsening ascites

      • Gastrointestinal hemorrhage, including variceal hemorrhage

      • Overt hepatic encephalopathy

      • Worsening nonobstructive jaundice

      • Bacterial infection associated with other organ failure

    • Precipitating factors include

      • Infections

      • Hemodynamic instability

      • Heavy alcohol use

      • Drug hepatotoxicity

Micronodular cirrhosis

  • Regenerating nodules are < 1 mm

  • Typical of alcoholic liver disease (Laennec cirrhosis)

Macronodular cirrhosis

  • Characterized by larger nodules, up to several centimeters in diameter, which may contain central veins

  • Corresponds to postnecrotic (posthepatitic) cirrhosis; but may not always follow identifiable episodes of massive necrosis and stromal collapse

Demographics

  • Eleventh leading cause of death globally

  • Eighth leading cause of death in the United States with a prevalence rate of 0.27%

  • Mexican Americans and African Americans have a higher frequency of cirrhosis than whites because of a higher rate of risk factors

Clinical Findings

Symptoms and Signs

  • Can be asymptomatic for long periods

  • Symptoms may be insidious or, less often, abrupt

  • Fatigue, disturbed sleep, muscle cramps, anorexia, and weight loss are common

  • Nausea and occasional vomiting

  • Reduced muscle strength and exercise capacity

  • Jaundice—usually not an initial sign—is mild at first, increasing in severity

  • Abdominal pain from hepatic enlargement and stretching of Glisson capsule or from ascites

  • Hematemesis is the presenting symptom in 15–25%

  • Fever

    • Present in up to 35%

    • Usually reflects associated alcoholic hepatitis, spontaneous bacterial peritonitis, or intercurrent infection

  • Amenorrhea in women

  • Erectile dysfunction, loss of libido, sterility, and gynecomastia in men

  • In 70% of cases, the liver is enlarged and firm with a palpable sharp or nodular edge; the left lobe may predominate

  • Splenomegaly occurs in 35–50%

  • Ascites, pleural effusions, peripheral edema, and ecchymoses are late findings

  • Relative adrenal insufficiency appears common in advanced cirrhosis, even in absence of sepsis

Encephalopathy

  • Characterized by

    • Day–night reversal

    • Asterixis

    • Tremor

    • Dysarthria

    • Delirium

    • Drowsiness

    • Coma

  • Occurs late except ...

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