LIVER CIRRHOSIS

Cirrhosis is a chronic disease with necrosis of liver cells followed by fibrosis and nodule formation. Decompensated
cirrhosis is defined by the presence of complications such as ascites, variceal bleeding, encephalopathy, or jaundice which result from the portal hypertension and liver insufficiency caused by cirrhosis.

Causes

  • Infections e.g. viral hepatitis B and D, hepatitis C
  • Intoxication with alcohol, drugs, or toxins e.g. methotrexate, isoniazid, methyldopa
  • Infiltrative disorders, e.g. non-alcoholic fatty liver disease, Wilson’s disease, haemochromatosis
  • Iron overload (e.g. in over transfused SCD patients)
  • Immunological, chronic autoimmune hepatitis
  • Congestion with bile e.g. primary biliary cirrhosis (PBC)
  • Congestion with blood e.g. chronic cardiac failure, Budd Chiari syndrome
  • Idiopathic

Clinical features

  • General symptoms: Fatigue, weight loss, features of malnutrition, nausea, vomiting and loss of appetite
  • Initially enlarged liver which later decreases in size
  • Distension of blood vessels on the abdomen
  • Enlarged spleen
  • Loss of libido

Cirrhosis is decompensated when the following are present:

  • Jaundice
  • Encephalopathy
  • Ascites (fluid in abdominal cavity) with or without leg oedema
  • Vomiting of blood from ruptured blood vessels in oesophagus (varices)
STAGE CLINICAL DEATH AT
1 YEAR
0 Fibrosis 1%
1 Compensated
cirrhosis
No varices
No ascites
1%
2 No ascites
Varices present
3%
3 Decompensated
cirrhosis
Ascites
± varices
20%
4 Bleeding
± ascites
57%
Spontaneous bacterial
peritonitis + sepsis
Renal failure
Hepatocellular
carcinoma
Jaundice
Hepatic
encephalopathy

Differential diagnosis

  • Diffuse hepatic parenchymal disease
  • Metastatic or multifocal cancer in the liver
  • Hepatic vein obstruction
  • Any cause of enlarged spleen
  • Heart failure, renal disease

Investigations

  • Blood: Hb, film, WBC, platelets, prothrombin time (INR), serology (hepatitis B, C, and D), HIV serology
  • Stool and urine
  • Abdominal ultrasound
  • Liver: Liver function tests, alpha fetoprotein, and biopsy
    • APRI score >2 is diagnostic
  • Endoscopy (for varices)

Management

Refer to a regional hospital or higher for the attention of specialist

General principles

  • Treat cause and prevent progression
    • Stop alcohol
    • Appropriate nutrition
    • If chronic hepatitis B, start antiviral treatment
    • Specific treatment according to the cause
    • Avoid herbs and self medication
    • Use medicines only after prescription from a health worker
  • Manage and prevent complications (see below)
    • Ascites
    • Encephalopathy
    • Bleeding varices