Cirrhosis

Key Features

Essentials of Diagnosis

• 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) and likely a genetic predisposition

• 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 another 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

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