Ciroza hepatica

Definitie
• Histopatologic – dezvoltarea fibrozei
hepatice extensive
pana la punctul in care apare

dezorganizare arhitecturala,
cu formarea

nodulilor de regenerare,
rezultand in

disfunctie hepatica.
 Etiologie
• Alcoolism

• Hepatite
– Hepatite cronice virale: VHB, VHC

– Hepatita autoimuna

– Steatohepatita nonalcoolica

• Bolile cailor biliare

– ciroza biliara primitiva, colangita sclerozanta primitiva

• Ciroza cardiaca

• Medicamente

• Boli metabolice ereditare: hemocromatoza, b Wilson,

• Ciroza criptogenica
Modificarile structurale hepatice
 Manifestari clinice
• Uneori absente
• Simptome: anorexie, greata, varsaturi, diaree,
durere vaga hipocondru drept, fatigabilitate,
febra, icter, amenoree, infertilitate

• Semne:
– stelute vasculare, eritem palmar, icter scleral,
– hipertrofie glande parotide si lacrimale,
– hepatosplenomegalie, ascita, edeme,
– sangerari GI (varice),
– encefalopatie hepatica,
– contractura Dupuytren,
– ginecomastie, atrofie testiculara
 Investigatii laborator
• Anemie
(microcitara - pierderi, macrocitara - deficit acid folat;
hemolitica)

• Pancitopenie - hipersplenism

• Tulburari de coagulare (tendinta hemoragica)

• Hipoalbuminemie
 Teste diagnostice
• AgHBs, Ac anti-HBc, Ac anti-HBs, Ac anti-VHC,
Ac anti VHD

• AutoAnticorpi in formele autoimune

• Ecografie abdominala + Doppler, CT / RMN

(ficat cirotic, splenomegalie, tromboze venoase)

• Diagnostic certitudine: biopsie hepatica

(percutana / transjugulara / deschisa)
 Complicatii ciroza
Hipertensiune portala
Varice gastroesofagiene

Ascita
Splenomegalie cu hipersplenism

Peritonita bacteriana spontana

Insuficienta renala
Tulburari hematologice
Encefalopatie hepatica Anemie
Hemoliza
Trombocitopenie
Malnutritie Neutropenie
Hipertensiunea portala
Portal hypertension (1)
Portal hypertension (2)
Portal hypertension -Esophageal Varices (a)
Portal hypertension –Caput Medusae (b)
Portal hypertension- Anorectal Varices
(c)
 Hipertensiunea portala
• Cresterea presiunii venoase in sistemul port

• Consecinte:

– varice esofagiene cu hemoragie,

– ascita,
– hipersplenism,
– encefalopatie hepatica,
– Cancer hepatic
 Encefalopatia hepatica
• Mecanism: neurotoxine

• Diferite grade de severitate : 0 (subclinica)

pana la gr 4 (coma)
• Diagnostic: de excludere
– clinic,
– amoniac seric,
– EEG,
– CT/RMN cerebral
 Tratament ciroza hepatica
• Masuri specifice in functie de cauza
( daca este posibil):
– interferon + agenti antivirali in VHB, VHC,

• Dietetic, suportiv + complicatii

• Transplant hepatic
 Tratament ascita
• Paracenteza  analize lichid: citologie, proteine,
albumina (SAAG), LDH, glucoza, culturi, rar
trigliceride, bilirubina

• Antibioterapie in caz de PBS

• Restrictie de sare
• Diuretice: furosemid, spironolactona
• Albumina

• Transplant hepatic
 Tratament encefalopatia
hepatica
• Evitare precipitanti (diuretice↑, hipovolemia,
I Renala, HDS, infectii, constipatie, TIPSS)

• Lactuloza
• Antibiotice – rifaximina (Normix)

• Nu se mai recomanda restrictia proteica

(beneficii ↓, risc accentuare malnutritie)
 Management varice esofagiene

• Monitorizare endoscopica

• Propranolol, nadolol – profilaxia sangerarii

• In caz de sangerare:
– EDS de urgenta - ligaturare,
– somatostatina/octreotide,
Varice esofagiene –
sangerare, ligaturare