Snapshot A 65-year-old man is brought to the emergency room for abdominal pain. He has a history of alcohol abuse. He reports that he has felt fatigued, itchy, and “out of it” for the past several weeks. His wife also noticed that his skin looks more orange. On exam, his abdomen is distended with a positive fluid wave. Dermatologic exam reveals jaundice, palmar erythema and spider angiomata. A hepatic ultrasound shows nodularity and fibrosis of the liver. Introduction Overview cirrhosis is a liver disease characterized by hepatic fibrosis, regenerative nodules, and dysfunction Epidemiology Incidence very common cause of death Risk factors alcoholic liver disease (most common) nonalcoholic steatohepatitis chronic viral hepatitis autoimmune hepatitis hepatocellular carcinoma primarily biliary cirrhosis α1-antitrypsin deficiency Wilson disease hemochromatosis ETIOLOGY Pathogenesis mechanism chronic liver damage results in nodules surrounded by fibrosis abnormal wound healing with continued connective tissue deposition, resulting in fibrosis results in damage to hepatic vasculature fibrosis causes shunting of portal and arterial blood impairs metabolism of estrogen Presentation Symptoms common symptoms fatigue weakness weight loss loss of appetite pruritus upper gastrointestinal bleeding Physical exam inspection mental status changes signs of liver disease jaundice gynecomastia ascites palmar erythema spider angiomata hepatosplenomegaly bleeding Imaging Liver ultrasound indications all patients findings fibrosis nodularity increased echogenicity atrophy or hypertrophy of liver lobes Transient elastography indications measures liver stiffness all patients findings hepatic fibrosis and increased stiffness Studies Serum labs multiple severity scores exist for cirrhosis but often include ↑ liver enzymes AST:ALT > 2 suggests alcoholic cirrhosis ↑ prothrombin time treat with fresh frozen plasma or factor replacement ↑ direct bilirubin ↓ platelets creatinine determining etiology hepatitis B and C serology alpha-1 antitrypsin levels antinuclear antibody anti-smooth muscle titers antimitochondrial antibody ferritin transferrin saturation levels 24-hour copper level in the urine ceruloplasmin hemochromatosis genetic testing Invasive studies liver biopsy indications patients who cannot undergo transient elastography clinical presentation is not consistent with a diagnosis Differential Acute viral hepatitis key distinguishing factor acute onset of symptoms with viral prodrome, nausea, vomiting, and abdominal pain lacks findings of chronic liver disease Treatment Management approach treat underlying cause if possible Lifestyle diet with restricted sodium indications all patients with ascites alcohol and smoking cessation Medical antibiotic prophylaxis for spontaneous bacterial peritonitis indications cirrhosis and gastrointestinal bleeding or ascites vaccinations indications all patients modalities hepatitis A hepatitis B 23-valent pneumococcal vaccine Surgical liver transplantation indications refractory liver cirrhosis major complications ascites variceal bleeding hepatic encephalopathy Complications Hepatocellular carcinoma screening liver ultrasound and alpha-fetoprotein every 6 months Spontaneous bacterial peritonitis Esophageal or gastric varices screening esophagogastroduodenoscopy (EGD) treatment banding TIPS procedure Hepatic hydrothroax ascites/fluid accumulation that enters the pleural space and impairs pulmonary mechanics treatment salt restriction (first-line) diuretics (loop or thiazide) Prognosis Model for End-Stage Liver Disease (MELD) score predicts 3-month mortality in patients with cirrhosis creatinine bilirubin INR