SIROSIS HATI

Dr.Suhaemi, SpPD, Finasim

Cirrhosis
Chronic generalized liver disease

A condition that is defined histopathologically

and has a variety of clinical manifestations and
complications, some of which can be life
threatening.

Pathologic features : development of fibrosis to

the point that there is architectural distortion
with formation of regenerative nodules
( micronodular / macronodular )

This results in decrease in hepatocellular mass,

thus function .
 Cirrhosis

Definition:

Hepatic necrosis and degeneration

combined with hepatic regeneration
and fibrosis leading to Nodular
NORMAL
Micronodular Cirrhosis
Macronodular Cirrhosis
HCC
Catabolism of hormones Glucose homeostasis;
and other serum proteins glycogenolysis & gluconeogenesis

CHRONIC LIVER
DISEASE
Synthesis:
- Albumin
- Coagulation factors
Storage:
Bile excretion - Glycogen
- Iron
- Cu, Iron, vitamins
Portal Vein
Receives 1050 mL/min from
Spleen
Intestines
Pancreas
Stomach
Incompletely saturated
Supplies 60-70% O2 needs
Empty into IVC
Stores 450 mL blood that can
be shifted in times of stress
 Circulation of the liver
Dual Blood Supply

Portal system
Hepatic veins drain liver
& empty into IVC
1000-1200 ml/min
(rich in nutrients)

Hepatic artery
400-500 ml/min blood
flow
Oxygenated blood
Liver Histology
 PATHOGENESIS OF LIVER FIBROSIS

Normal
Normal Hepatic
Hepatic SInusoid
SInusoid

Retinoid
Retinoid
droplets
droplets
Fenestrae
Fenestrae

Hepatic
stellate cell
Space
Space of
of Disse
Disse

Sinusoidal
Sinusoidal
endothelial
endothelial cell
cell

Hepatocytes
Hepatocytes
 PATHOGENESIS OF LIVER FIBROSIS

Alterations
Alterations in Microvasculature in Cirrhosis
Cirrhosis

Activation
Activation of
of stellate cells
Collagen
Collagen deposition
deposition inin space
space of
of
Disse
Disse
Constriction
Constriction of sinusoids
Defenestration
Defenestration of sinusoids
 1. Atrterial
3. Venous System
System

2. Capillary
System
 5. Venous
System

4. Second
Visceral
Capillary
System 2. First
1. Atrterial
3. Venous Visceral System
System Capillary
3. Visceral System
Venous
System

2. Capillary
System
 COMPLICATIONS OF CIRRHOSIS

Complications of Cirrhosis Result from Portal

Hypertension or Liver Insufficiency

Variceal
Portal hemorrhage
hypertension Spontaneous
Spontaneous
bacterial
bacterial
peritonitis
peritonitis
Ascites
Cirrhosis Hepatorenal
Hepatorenal
syndrome
syndrome

Encephalopathy
Liver
insufficiency
Jaundice
 Overview of liver pathophysiology

Inflammation Obstruction
Edema internal pressure
pressure
external pressure

Hepatocellular damage
breakdown of urea NH3
encephalopathy
absorption of fat soluble vitamins (Vit. K)
synthesis of clotting factors bleeding
synthesis of plasma proteins (albumin)
malnutrition & edema
Signs of CLD
Nutrition & Diet Therapy, 7th Edition
ULTRASOUND IS THE MOST SENSITIVE METHOD TO DETECT ASCITES

Ultrasound is the Most Sensitive Method

to Detect Ascites

Ascites
Ascites

Liver
Liver
 Endocrine Problems
Gynecomastia
Loss of axillary/pubic hair
Testicular atrophy
libido/impotence

Na
H20
hyperaldosteronism

K
Esophageal Varices
Gastric & esophageal varices
Clinical Manifestations
Muehrcke's
nails

Terrys nails
Palmar erythema
Spider Nevi
SPIDER NEAVI
Dupuytren's Contracture
Ascites in End Stage Liver Disease
PBC
Portal Hypertension

HCC

Ascites

Varices
 HEPATIC ENCEPHALOPATHY
Precipitating factors
GI Bleeding
Excess protein intake
Electrolyte abnormalities, Ascitic Aspiration
Uremia
Dehydration, Constipation
Alcohol
Viral infections, SBP
Anaesthetic agents, Surgery, Narcotics, Tranquilisers
Hepatic toxins, Portosystemic shunts - TIPS
 HEPATIC ENCEPHALOPATHY
TreatmentCORRECT/ AVOID PRECIPITATING
FACTORS
Dietary protein restriction-30 - 40 gm protein / day
Non absorbable disaccharide LACTULOSE 15
to 45 ml BID / QID
Lactulose enema
Neomycin 1 gm 6th hrly
Metronidazole 250 mg 8th hrly
Bowel wash / Lactobacillus
 NUMBER CONNECTION TEST

Number
Number Connection
Connection Test
Test Draw
Draw aa star
star
70
(NCT)
(NCT)
Time
Time to
to
complete____________________
complete____________________

End
End
66 10
10 25
25
44
77 99 23
23
11 11
11
55 Begin
Begin

14
14
88 24
24
33
22 Sample
Sample handwriting
handwriting
13
13
12
12
17
17
15
15 16
16 22
22
18
18 21
21
19
19 20
20
 ELECTROENCEPHALOGRAM IN HEPATIC ENCEPHALOPATHY

Electroencephalogram in Hepatic
Encephalopathy
GRADING OF HEPATIC ENCEPHALOPATHY

0 Normal
1 Inverted sleep rhythm, restless
2 Lethargy, slow response
3 Drowsy, arousable but confused
4 - Coma
CHILD PUGH Scoring
Clinical and biochemical Points scored for increasing
measurements abnormality
1 2 3

Albumin (g/dl) > 3.5 2.8 to 3.5 < 2.8

Bilirubin (mg/dl) 1 to 2 2 to 3 >3
For cholestatic <4 4 to 10 > 10
diseases : bilirubin
(mg/dl)
PT (secs prolonged)* 1 to 4 4 to 6 >6
Or < 1.7 1.7 to 2.3 > 2.3
INR*
Ascites Absent Slight Moderat
 Ascites
Pathophysiology/Interventions
PRO leak through liver capsule to
peritoneal cavity oncotic pressure of
PRO pulls more fluid

albuminemia d/t livers inability to

synthesize PRO colloidal osmotic Fowlers Position
pressure Pro, Na diet
mouth care/
aldosteronism d/t livers inability to dehydration
metabolize aldosterone Na
reabsorption serum osmolarity K-sparing diuretics
ADH secretion water retention Paracentesis
Salt Poor Albumin
Peritoneovenous Shunt

Fig.
PERITONEO-VENOUS SHUNT (PVS) IS USEFUL IN THE TREATMENT OF REFRACTORY ASCITES

Peritoneo-Venous Shunt (PVS) is

Useful in the Treatment of Refractory
Ascites
Use
Use of
of jugular
vein
vein will
will hinder
hinder
TIPS
TIPS placement
placement

One-way
One-way
valve
valve
Intraabdominal
Intraabdominal
adhesions
adhesions may
may
complicate
complicate liver
transplant
transplant surgery
surgery
Sengstaken-Blakemore Tube

Fig. 42-
Shunts T.I.P.S.
Black-1158
Portosystemic Shunts

Fig. 42-
 NUMBER CONNECTION TEST

Number
Number Connection
Connection Test
Test Draw
Draw aa star
star
70
(NCT)
(NCT)
Time
Time to
to
complete____________________
complete____________________

End
End
66 10
10 25
25
44
77 99 23
23
11 11
11
55 Begin
Begin

14
14
88 24
24
33
22 Sample
Sample handwriting
handwriting
13
13
12
12
17
17
15
15 16
16 22
22
18
18 21
21
19
19 20
20