Cirrhosis

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."

Cause / etiology

The two most common causes, at least in women, may be alcoholism which causes alcoholic hepatitis and obesity with causes steatohepatitis. These two risks may have a "supra-additive interaction."

Diagnosis

Clinical prediction rules exist to help diagnosis cirrhosis.

• Pohl's Index is if the AST/ALT ratio ≥1 and platelet count ≤ 150,000/mm³ then cirrhosis is very likely.
• The Bonacini score is based on the ALT/AST ratio, platelet count, and INR.
  • A score of > 7 or 8 makes cirrhosis more likely.
  • A score of < 3 makes cirrhosis less likely.

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:

• Sensitivity = 79%
• Specificity = 78%

Complications

Clinical practice guidelines are available for the treatment of cirrhosis and its complications.

Esophageal varices

A clinical prediction rule is available to help detect patients at risk of esophageal varices. For predicting clinically significant portal hypertension(hepatic venous pressure gradient ≥ 10 mmHg):

$Risk\ score\ =\ -0.193+(-0.359\times albumin)+(16.456\times INR)+(-0.0016\times ALT)$

Risk score = -0.193 + (-0.359*albumin) + (16.456*INR) + (-0.0016*ALT)

At a cutoff value >0.06 the accuracy is:

• Sensitivity 93%
• Specificity 61%

For predicting esophagel varices:

$Risk\ score\ =\ -5.418+(-0.131\times albumin)+(1.949\times spider\ angiomas)+(-0.008\times ALT)$

(spider angiomas = 1 if present and 0 if absent)

At a cutoff value >-1.02 the accuracy is:

• Sensitivity 93%
• Specificity 37%

Patients with a thrombocytopenia and a palpable spleen are more likely to have large esophageal varices. The cutoff for thrombocytopenia ranges from 40,000 to 150,000.

Treatment of bleeding

Transjugular intrahepatic portosystemic shunt may also add to endoscopic therapy for acute bleeding of esophageal varices.

Emergency portacaval shunt may be a better treatment than endoscopic sclerotherapy.

Prevention of bleeding

It is not clear that adding endoscopic band ligation to nadolol, an adrenergic_beta-antagonist, reduces bleeding.

Spontaneous bacteremia

Spontaneous bacteremia may occur. Mong patients with Child-Pugh Score indicating class C, half of bacteremias may not have a definite focus.

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.