LIVER CIRRHOSIS

LIVER

Prepared by: Sharifa Mietan

Supervision : Dr.Hassan Bayashoot

Liver cirrhosis
Liver cirrhosis

Cirrhosis is a diffuse injury to the liver characterized by fibrosis and

conversion of the normal hepatic architecture into structurally abnormal
nodules. The end result is destruction of hepatocytes and their
replacement by fibrous tissue.

Cirrhosis is generally irreversible once it occurs, and

generally treatment focuses on prevent progression and
.complications
Etiology of Cirrhosis

Chronic alcohol consumption

Chronic viral hepatitis (types B and C)
 Signs and symptoms

Asymptomatic

Hepatomegaly and splenomegaly

Pruritus, jaundice, palmar erythema, spider angiomata, and hyperpigmentation

Gynecomastia

edema, pleural effusion, and respiratory difficulties ,

Malaise, anorexia, and weight loss

Encephalopathy
Laboratory tests

Hypoalbuminemia
Elevated prothrombin time (PT)(
Thrombocytopenia
Elevated alkaline phosphatase (AST)
Elevated aspartate transaminase, alanine transaminase ALT), and γ-

glutamyl transpeptidase dase (GGT)

Complicatiuons
Ascites

Esophageal varices
‫ دوالي المرئ‬bleeding &

Hepatorenal syndrome
Complicatiuons

Immune dysfunction

Pruritus
Sensitive to medication , hepatocellular
carcinoma

Hepatic encephalopathy
 Treatment:
1- Management of portal hypertension and variceal bleeding.
2- Ascites
3- Spontaneous bacterial peritonitis
4- Hepatic encephalopathy
MANAGEMENT OF PORTAL HYPERTENSION AND VARICEAL BLEEDING
•
The management of varices involves three strategies: (1) primary prophylaxis to prevent
rebleeding, (2) treatment of variceal hemorrhage, and (3) secondary prophylaxis
.to prevent rebleeding in patients who have already bled

Primary Prophylaxis#
.
The mainstay of primary prophylaxis is the use of a nonselective β-adrenergic blocking •
agent such as propranolol or nadolol. These agents reduce portal pressure by
reducing portal venous inflow via two mechanisms: decrease in cardiac output and
.decrease in splanchnic blood flow
Therapy should be initiated with propranolol, 20 mg twice daily, or nadolol, 20 to 40 •
mg once daily, and titrated every 2 to 3 days to maximal tolerated dose to heart rate
..of 55 to 60 beats/min

Patients with contraindications to therapy with nonselective β-adrenergic blockers •

,ie, those with asthma, insulin-dependent diabetes with episodes of hypoglycemia(
and peripheral vascular disease) or intolerance to β-adrenergic blockers should be
considered for alternative prophylactic therapy with EVL
:Acute variceal hemorrhage

Prompt stabilization of blood volume to maintain hemoglobin of 8 g/dL with volume

expansion to maintain systolic blood pressure of 90 to 100 mm Hg and heart rate of less than
100 beats/min is recommended. Airway management is critical. Fluid resuscitation involves
colloids initially and subsequent blood products. Vigorous resuscitation with saline solution
should generally be avoided

. Vasoactive drug therapy (usually octreotide) to stop or slow bleeding .

Octreotide is administered as an IV bolus of 50 mcg followed by a continuous infusion of 50
.mcg/h. It should be continued for 5 days after acute variceal bleeding
Patients should be monitored for hypo- or hyperglycemia
Vasopressin, alone or in combination with nitroglycerin, is not recommended as firstline therapy •
for the management of variceal hemorrhage. Vasopressin causes nonselective vasoconstriction and
can result in myocardial ischemia or infarction, arrhythmias, mesenteric ischemia, ischemia of the
.limbs, or cerebrovascular accidents

Antibiotic therapy should be used early to prevent sepsis in patients with signs of infection or •
ascites. A short course (up to 7 days) of oral norfloxacin 400 mg twice daily or IV ciprofloxacin is
.recommended

EVL is the recommended form of endoscopic therapy for acute variceal bleeding, although •
endoscopic injection sclerotherapy (injection of 1–4 mL of a sclerosing agent into the lumen of the
.varices) may be used

If standard therapy fails to control bleeding, a salvage procedure such as balloon tamponade (with •
a Sengstaken-Blakemore tube) or transjugular intrahepatic portosystemic shunt (TIPS) is necessary
 Ascites
The treatment of ascites secondary to portal hypertension includes abstinence from alcohol, •
sodium restriction (to 2 g/day), and diuretics. Fluid loss and weight change depend directly on
sodium balance in these patients. A goal of therapy is to increase urinary excretion of sodium
.to greater than 78 mmol/day

Diuretic therapy should be initiated with single morning doses of spironolactone,100 mg, •
and furosemide, 40 mg, titrated every 3 to 5 days, with a goal of 0.5 kg maximum daily
weight loss. The dose of each can be increased together, maintaining the 100:40 mg ratio, to a
.maximum daily dose of 400 mg spironolactone and 160 mg furosemide

If tense ascites is present, paracentesis should be performed prior to institution of diuretic •

.therapy and salt restriction

..Liver transplant should be considered in patients with refractory ascites •

 SPONTANEOUS BACTERIAL PERITONITIS

Antibiotic therapy for prevention of spontaneous bacterial peritonitis (SBP) should be •

considered in all patients who are at high risk for this complication (those who experience a
prior episode of SBP or variceal hemorrhage and those with low-protein ascites)
Patients with documented or suspected SBP should receive broad-spectrum antibiotic •
therapy to cover Escherichia coli, Klebsiella pneumoniae, and Streptococcus pneumoniae
 Antibiotic for SBP

Cefotaxime, 2 g every 8 hours, or a similar third-generation cephalosporin for 5 days is

considered the drug of choice. Oral ofloxacin, 400 mg every 12 hours for 8 days, is
.equivalent to IV cefotaxime
Patients who survive an episode of SBP should receive long-term antibiotic prophylaxis •
with daily norfloxacin 400 mg or double-strength trimethoprim-sulfamethoxazole
Hepatic encephalopathy (HE)
 Treatment of HE
To reduce blood ammonia concentrations in episodic HE, lactulose is initiated at •
mL orally every hour (or 300 mL lactulose syrup with 700 mL water given as 45
a retention enema held for 60 minutes) until catharsis begins. The dose is then
decreased to 15 to 30 mL orally every 8 to 12 hours and titrated to produce two or
.three soft stools per day
Antibiotic therapy with metronidazole or neomycin is reserved for patients who •
have not responded to diet and lactulose. Rifaximin 550 mg twice daily plus lactulose
.can be used for patients with inadequate response to lactulose alone
Zinc acetate supplementation (220 mg twice daily) is recommended for long-term •
management in patients with cirrhosis who are zinc deficient
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