Cirrhosis

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Referral

Definition

Cirrhosis is a chronic liver disease characterised by progressive fibrosis and nodular regeneration, leading to impaired liver function and portal hypertension.

Aetiology

Cirrhosis results from chronic liver injury due to:

  • Alcohol-related liver disease (ARLD): chronic alcohol consumption leading to hepatocyte damage.
  • Non-alcoholic fatty liver disease (NAFLD): caused by obesity, diabetes, and metabolic syndrome.
  • Chronic viral hepatitis: hep B and C infections.
  • Autoimmune liver diseases: primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), autoimmune hepatitis.
  • Genetic conditions: wilson’s disease, haemochromatosis, alpha-1 antitrypsin deficiency.
  • Biliary obstruction: long-term bile duct disease leading to fibrosis.

Pathophysiology

  • Chronic liver injury triggers inflammation and activation of hepatic stellate cells.
  • These cells produce excess collagen, leading to fibrosis and distortion of normal liver architecture.
  • Fibrosis results in impaired liver function, portal hypertension, and hepatocellular dysfunction.

Risk factors

  • Chronic alcohol use.
  • Obesity and metabolic syndrome (risk of NAFLD).
  • Chronic viral hepatitis (hepatitis B and C).
  • Family history of liver disease.
  • Exposure to hepatotoxic drugs (e.g., methotrexate, amiodarone).

Signs and symptoms

Symptoms:

  • Fatigue and weakness.
  • Loss of appetite and weight loss.
  • Abdominal distension (ascites).
  • Jaundice (yellowing of the skin and sclera).
  • Easy bruising or bleeding.
  • Confusion and memory impairment (hepatic encephalopathy).

Signs:

  • Hepatomegaly (enlarged liver).
  • Splenomegaly (enlarged spleen).
  • Ascites (fluid accumulation in the abdomen).
  • Caput medusae (dilated abdominal veins).
  • Spider naevi (small dilated blood vessels on the skin).
  • Palmar erythema (red palms).
  • Flapping tremor (asterixis, seen in hepatic encephalopathy).

Investigations

  • Blood tests:
    • Liver function tests (LFTs): raised ALT, AST, ALP, and bilirubin.
    • Low albumin and prolonged INR (indicating liver dysfunction).
    • Full blood count (FBC): thrombocytopenia in portal hypertension.
    • Serum ammonia: raised in hepatic encephalopathy.
  • Imaging:
    • Ultrasound: check liver structure and portal hypertension.
    • FibroScan (transient elastography): check liver fibrosis severity.
    • CT/MRI: if hepatocellular carcinoma is suspected.
  • Liver biopsy: to confirm cirrhosis and assess fibrosis.

Management

1. Lifestyle and Preventative Measures:

  • Alcohol cessation: in alcohol-related liver disease.
  • Weight management: critical in NAFLD.
  • Vaccination: hep A, B, and pneumococcal vaccines.
  • Avoid hepatotoxic medications: NSAIDs, certain antibiotics, and herbal remedies.

2. Medical Management:

  • Ascites: fluid restriction, salt restriction, and diuretics (spironolactone ± furosemide).
  • Hepatic encephalopathy: treated with lactulose and rifaximin.
  • Variceal bleeding prevention: beta-blockers (e.g., propranolol) for portal hypertension.
  • Hepatocellular carcinoma surveillance: 6-monthly ultrasound and AFP measurement.

3. Surgical and Interventional Management:

  • Endoscopic band ligation: for oesophageal varices.
  • Transjugular intrahepatic portosystemic shunt (TIPS): used in refractory portal hypertension.
  • Liver transplantation: main treatment for end-stage liver disease.

Referral

  • Gastroenterology referral: for diagnosis, staging, and management planning.
  • Hepatology referral: for consideration of liver transplantation.
  • Urgent referral: if there is decompensated cirrhosis (ascites, encephalopathy, variceal bleeding).
GastroenterologymypanotesCirrhosis