Cirrhosis

Hepatic cirrhosis is the reconstruction of the lobular structure of the liver into a nodular structure ( hepatocyte death, replaced by connective tissue, the remaining parenchyma regenerates + forms nodules) as a result of chronic liver disease.

Etiology

 * chronic hepatitis C, B, B + D - posthepatitic cirrhosis ,
 * alcoholic liver damage - alcoholic cirrhosis ,
 * long-term biliary obstruction - biliary cirrhosis ,
 * primary - autoimmune diseases ( antibodies against interlobular bile ducts are formed ),
 * secondary - due to prolonged biliary obstruction by tumor or concretion ,
 * primary sclerosing cholangitis - autoimmune disease of intrahepatic and extrahepatic bile ducts,

The consequences of liver cirrhosis (and underlying complications) are:
 * toxic liver damage ( paracetamol, amatoxin…) - toxic cirrhosis,
 * metabolic diseases ( Wilson's disease, α1-antitrypsin deficiency, hemochromatosis , porphyria , CF and others),
 * long-lasting venostasis - cirrhosis due to venous congestion,
 * unclear etiology - cryptogenic cirrhosis (in 10–15%).


 * impaired synthetic function of the liver (especially proteosynthesis ) by the death of hepatocytes - liver insufficiency ,
 * portal hypertension.

== Complications of cirrhosis ==

thumb|vpravo|300px|Mikronodulární jaterní cirhóza
 * portal hypertension - congestion in the Vena portae basin, consequences:
 * esophageal varices - massive bleeding ( hematemesis, melena )
 * ascites - fluid and sodium retention by the kidneys ( hyperaldosteronism - impaired degradation in the liver), hypoproteinemia is less important
 * splenomegaly - platelet sequestration in the spleen - thrombocytopenia

reduced resistance to infection (limited blood flow to the liver eliminates liver RES ) - pneumonia, SBP
 * bleeding ( hemorrhagic diathesis ) - insufficient synthesis of coagulation factors, hypersplenism with thrombocytopenia
 * jaundice - not always expressed
 * spider nevi (naevus araneus, extension of the terminal sections of skin arterioles) - especially on the hands, forearms, forehead and front of the chest
 * liver failure
 * renal failure ( hepatorenal syndrome )
 * hepatocellular carcinoma
 * hyperestrism - a disorder of the breakdown of estrogen by the liver, excess leads to testicular atrophy and gynecomastia in men, and menstrual disorders and ovarian atrophy in women
 * encephalopathy

Clinical picture
Hepatic cirrhosis can be asymptomatic for a long time and is diagnosed at random (preventive examinations, abdominal surgery, etc.).

Compensated cirrhosis (latent subclinical)

 * very reminiscent of chronic hepatitis
 * subjectively, patients complain of non-specific symptoms: dyspepsia - feelings of fullness after eating, stool changes; in women menses disorders, hypomenorrhea to amenorrhea
 * objectively : hepatosplenomegaly, slow-growing portal hypertension , skin symptoms - spider nevi, manifestations of bleeding, mild perimalleolar swelling , nocturia, sudden hematemesis

Decompensated cirrhosis (advanced)
Physical finding:
 * varied symptomatology
 * symptoms of parenchymatous liver disorders (metabolic decompensation) - jaundice, hemorrhagic diathesis , hypoalbuminemia with fluid retention with ascites and edema
 * symptoms of advanced portal hypertension (vascular decompensation) - ascites, esophageal varices, portosystemic encephalopathy
 * subjectively - insurmountable fatigue, weakness, exhaustion, loss of appetite, weight loss, abdominal enlargement, swelling; in women menses to amenorrhoea disorders, in men decreased libido and potency, gynecomastia, often arthralgia and spine pain
 * objectively - patient tired, emaciated (large abdomen, thin limbs), slow reactions (encephalopathy), subfebrile, hypothermia or isothermia, skin pale, often icteric, numerous spider nevi, lips and tongue are red (varnished), palmar erythema on the hands, Dupuytren's contracture , white nails, clubbed fingers , hemorrhagic diathesis (petechiae, hematomas, bleeding from the gums, nose, gynecological), in men the chest hair disappears ( Tail's habitus ), gynecomastia


 * aspects: arching of the right lower jaw, jaundice, spider nevi, palmar erythema, etc.
 * palpation: splenomegaly, may be hepatomegaly
 * percussion: may be hepatomegaly, evidence of ascites (glacial symptom)

Diagnosis
thumb|350px|Mikroskopický obraz jaterní cirhózy
 * anamnesis and physical examination
 * laboratory examination
 * increased AST and ALT, hyperbilirubinemia
 * thrombocytopenia, leukopenia (hypersplenism)
 * hypoalbuminemia, hypergammaglobulinemia, ↑ erythrocyte sedimentation
 * prolongation of prothrombin time
 * decompensation of cirrhosis results in an increase in ammonia and a decrease in uremia
 * in biliary cirrhosis, obstructive enzymes ( ALP, GMT )
 * hepatitis serology
 * autoantibodies in autoimmune cirrhosis
 * AFP in the transition to cancer


 * imaging methods ( ultrasound or CT of the liver, endoscopy to detect varicose veins)
 * liver biopsy

Treatment

 * 1) influencing the underlying disease  – abstinence in alcoholics, treatment of hepatitis , penicillamine in Wilson's disease
 * 2) supportive measures  – regime measures (alcohol abstinence, omission of hepatotoxic drugs), administration of vitamins A, D, E, K], hepatoprotectants, in autoimmune hepatitis (nowhere else) [[corticoids are given
 * 3) liver transplantation
 * 4) treatment of complications:
 * bleeding from esophageal varices (endoscopic sclerosing or ligation + terlipressin (Remestyp), in case of TIPS failure or surgery, after bleeding GIT and ATB lavage, preventive administration of non-selective β-blockers and nitrates)
 * hepatic encephalopathy (restriction of protein intake, lactulose, ATB, administration of branched-chain amino acids )
 * ascites (restriction of fluid and salt intake, diuretics (spironolactone + furosemide), puncture, TIPS, shunt)
 * hepatorenal syndrome (Remestype in combination with iv albumin)
 * hepatocellular carcinoma (surgical resection or radiofrequency ablation, palliative chemoembolism)

Prognosis
The Child-Pugh score is used to predict liver cirrhosis.

Score used to evaluate the prognosis of a patient with chronic liver failure.

Related Articles

 * Pseudolobular cirrhosis (specimen)