Cirrhosis

🩸 Cirrhosis is the irreversible end stage of chronic liver disease, characterised by widespread fibrosis, nodular regeneration, and loss of normal hepatic architecture. ➡️ This distortion leads to portal hypertension, synthetic failure, and increased risk of hepatocellular carcinoma (HCC). 💡 Key concept: Cirrhosis = “scarring + nodules” → both impaired function + obstruction of blood flow.

⚙️ Pathophysiology

• 🔄 Chronic injury → hepatocyte necrosis → activation of stellate cells → collagen deposition → bridging fibrosis.
• 🌀 Regenerating hepatocytes form nodules surrounded by fibrous septae.
• 💢 Fibrosis distorts sinusoidal architecture → ↑ intrahepatic resistance → portal hypertension.
• ⚠️ Consequences: – Varices (collateral formation). – Splenomegaly (hypersplenism). – Ascites (splanchnic vasodilation + RAAS activation). – Hepatic encephalopathy (ammonia accumulation).

📌 Causes of Cirrhosis

• 🦠 Chronic Viral Hepatitis (B & C) – treat with antivirals (entecavir, tenofovir, DAAs).
• 🍺 Alcoholic Liver Disease – abstinence crucial; steroids if severe alcoholic hepatitis.
• ⚖️ NAFLD/NASH – linked to obesity, diabetes, metabolic syndrome; lifestyle modification key.
• 🧬 Autoimmune Hepatitis – ANA, SMA, LKM1 +ve; treat with prednisolone ± azathioprine.
• 🌿 PBC – cholestatic picture, AMA +ve; treat with ursodeoxycholic acid.
• 🌀 PSC – associated with IBD; risk of cholangiocarcinoma; transplant definitive.
• 🩸 Haemochromatosis – iron overload; treat with venesection/chelation.
• 🥉 Wilson’s Disease – copper accumulation; treat with penicillamine or zinc.
• 🫁 Alpha-1 Antitrypsin Deficiency – early cirrhosis ± emphysema; transplant if severe.
• 📡 Other: drugs (methotrexate, amiodarone), toxins, chronic biliary obstruction.

👀 Clinical Signs

• 🟡 Jaundice – bilirubin accumulation.
• 💧 Ascites + peripheral oedema – portal HTN + hypoalbuminaemia.
• 🕷️ Spider naevi, ✋ palmar erythema, 👨 gynaecomastia – hyperoestrogenism.
• 🩸 Splenomegaly + caput medusae – collateral circulation.
• 🧠 Hepatic encephalopathy – confusion, asterixis, coma.
• 📉 Sarcopenia, weight loss, malnutrition.
• 🤕 Easy bruising – impaired clotting factor synthesis.

📊 Assessing Severity

• 🧮 Child–Pugh Score: Bilirubin, albumin, INR, ascites, encephalopathy → A (mild), B (moderate), C (severe).
• 📑 MELD Score: Bilirubin, creatinine, INR, sodium → transplant listing (6–40).
• 🔎 FibroScan: Non-invasive fibrosis staging.
• 📌 Biopsy: Gold standard (less used if non-invasive tests sufficient).
• 🧭 Compensated vs Decompensated: – Compensated = preserved function, often asymptomatic. – Decompensated = ascites, variceal bleed, encephalopathy, jaundice.

⚠️ Major Complications & Management

• 💧 Ascites: Salt restriction + spironolactone ± furosemide; paracentesis; TIPS if refractory.
• 🦠 SBP: Ascitic neutrophils >250; treat with IV cefotaxime + albumin; prophylaxis with norfloxacin/trimethoprim.
• 🩸 Variceal Bleeding: Resuscitate, IV octreotide, endoscopic banding; prophylaxis with carvedilol/propranolol.
• 🧠 Hepatic Encephalopathy: Lactulose (titrate to 2–3 soft stools/day) ± rifaximin; correct triggers.
• 🧂 Hepatorenal Syndrome: Albumin + terlipressin; transplant definitive.
• 🎯 HCC: Screen with US + AFP q6 months; treat with resection, transplant, RFA, TACE, or systemic agents (sorafenib, lenvatinib).
• 🩹 Coagulopathy: Vit K, FFP/platelets if bleeding; avoid unnecessary anticoagulation reversal unless urgent.

⚕️ Long-Term Management Principles

• 🚭 Lifestyle: Alcohol abstinence, weight control, vaccination (HAV, HBV, influenza, pneumococcus).
• 🧪 Monitor: Regular US + AFP (HCC screening), endoscopy for varices.
• 💉 Transplant: Definitive for decompensated cirrhosis or HCC within Milan criteria.
• 🤝 MDT: Hepatology, transplant surgery, dietetics, palliative care.

📚 References

• NICE CKS: Cirrhosis
• BSG Guidelines: Cirrhosis in Adults
• Kumar & Clark’s Clinical Medicine, 10th ed.