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| {{Infobox_Disease | | | {{Infobox_Disease | |
| Name = {{PAGENAME}} | | | Name = {{PAGENAME}} | |
| Image = Cirrhosis 030.jpg | | | Image = Cirrhosis 030.jpg | |
| Caption = Gross, natural color of liver and stomach view from external surfaces, micronodular cirrhosis and hemorrhagic gastritis (as the surgeon would see these in natural color). <br> <small> [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology] </small> | | | Caption = Gross, natural color of liver and stomach view from external surfaces, micronodular cirrhosis and hemorrhagic gastritis (as the surgeon would see these in natural color). <br> <small> [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology] </small> | |
| DiseasesDB = 2729 |
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| ICD10 = {{ICD10|K|70|3|k|70}}, {{ICD10|K|71|7|k|70}}, {{ICD10|K|74||k|70}} |
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| ICD9 = {{ICD9|571}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| MeshID = D008103 |
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| }} | | }} |
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| {{Cirrhosis}} | | {{Cirrhosis}} |
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| {{SI}}
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{CMG}}; | | {{CMG}}; {{AE}} {{Cherry}} |
| {{AE}} {{CZ}}; {{ADI}} | |
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| ==[[Cirrhosis overview|Overview]]==
| | {{SK}} Cirrhosis of liver; hepatic fibrosis; hepatic sclerosis |
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| ==[[Cirrhosis historical perspective|Historical Perspective]]== | | == [[Cirrhosis overview|Overview]] == |
| ==[[Cirrhosis classification scheme| Classification]]==
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| | == [[Cirrhosis historical perspective|Historical Perspective]] == |
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| ==[[Cirrhosis pathophysiology| Pathophysiology]]== | | == [[Cirrhosis classification|Classification]] == |
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| ==[[Cirrhosis causes| Causes]]== | | == [[Cirrhosis pathophysiology|Pathophysiology]] == |
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| ==[[Cirrhosis differential diagnosis| Differential Diagnosis]]== | | == [[Cirrhosis causes|Causes]] == |
| ==[[Cirrhosis epidemiology and demographics|Epidemiology and Demographics]]==
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| ==[[Cirrhosis risk factors | Risk Factors]]==
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| ==[[Cirrhosis natural history | Natural History, Complications and Prognosis]]== | | == [[Cirrhosis differential diagnosis|Differentiating Cirrhosis from other Diseases]] == |
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| ==Diagnosis== | | == [[Cirrhosis epidemiology and demographics|Epidemiology and Demographics]] == |
| [[Cirrhosis symptoms|Symptoms]] | [[Cirrhosis physical examination|Physical Examination]] |[[Cirrhosis laboratory tests|Laboratory tests]] | [[Cirrhosis electrocardiogram|ECG]] | [[Cirrhosis endoscopy| Endoscopy]] |[[Cirrhosis CT|CT]] | [[Cirrhosis MRI|MRI]] |[[Cirrhosis echocardiography or ultrasound|Echocardiography or Ultrasound]] |[[Cirrhosis other imaging findings|Other imaging studies]] | [[Cirrhosis other diagnostic studies|Alternative diagnostics]] | |
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| ==Treatment== | | == [[Cirrhosis risk factors|Risk Factors]] == |
| [[Cirrhosis medical therapy|Medical therapy]] | [[Cirrhosis surgery|Surgical options]] | [[Cirrhosis prevention|Prevention]] | [[Cirrhosis cost-effectiveness of therapy|Financial costs]]| [[Cirrhosis future or investigational therapies|Future therapies]] | |
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| | == [[Cirrhosis screening|Screening]] == |
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| | == [[Cirrhosis natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
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| | == Diagnosis == |
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| ==Diagnosis==
| | [[Cirrhosis history and symptoms|History and Symptoms]] | [[Cirrhosis physical examination|Physical Examination]] | [[Cirrhosis laboratory findings|Laboratory Findings]] | [[Cirrhosis electrocardiogram|Electrocardiogram]] | [[Cirrhosis chest x ray|Chest X Ray]] | [[Cirrhosis CT|CT]] | [[Cirrhosis MRI|MRI]] | [[Cirrhosis echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Cirrhosis other imaging findings|Other Imaging Findings]] | [[Cirrhosis other diagnostic studies|Other Diagnostic Studies]] | [[Cirrhosis Clinical prediction rules|Clinical prediction rules]] |
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| ===Imaging=== | | == Treatment == |
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| ===Other Diagnostic Modalities===
| | [[Cirrhosis medical therapy|Medical Therapy]] | [[Cirrhosis surgery|Surgery]] | [[Cirrhosis primary prevention|Primary Prevention]] | [[Cirrhosis secondary prevention|Secondary Prevention]] | [[Cirrhosis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Cirrhosis future or investigational therapies|Future or Investigational Therapies]] |
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| If biliary pathology ([[primary sclerosing cholangitis]] - [[PSC]]) is suspected, [[Endoscopic retrograde cholangiopancreatography|ERCP]] may be performed.
| | ==Case Studies== |
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| Generally [[Magnetic resonance cholangiopancreatography|MRCP]] (MRI of biliary tract and pancreas) is sufficient for diagnosis, but ERCP allows for particular interventions, such as placement of a biliary [[stent]] or extraction of gallstones.
| | [[Cirrhosis case study one|Case #1]] |
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| ==Grading==
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| The severity of cirrhosis is commonly classified with the [[Child-Pugh score]]. This score uses [[bilirubin]], [[human serum albumin|albumin]], [[prothrombin time|INR]], presence and severity of [[ascites]] and [[Hepatic encephalopathy|encephalopathy]] to classify patients in class A, B or C; class A has a favourable prognosis, while class C is at high risk of death. It was devised in 1964 by Child and Turcotte and modified in 1973 by Pugh ''et al''.<ref>Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. ''Br J Surg'' 1973;60:646-9. PMID 4541913.</ref>
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| More modern scores, used in the allocation of [[liver transplant]]s but also in other contexts, are the [[Model for End-Stage Liver Disease]] (MELD) score and its pediatric counterpart, the [[Pediatric end-stage liver disease|Pediatric End-Stage Liver Disease]] ([[PELD]]) score.
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| ==Treatment==
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| Traditionally, liver damage from cirrhosis cannot be reversed, but treatment could stop or delay further progression and reduce complications. A healthy diet is encouraged, as cirrhosis may be an energy-consuming process. Close follow-up is often necessary. Antibiotics will be prescribed for infections, and various medications can help with itching. Laxatives, such as [[lactulose]], decrease risk of constipation; their role in preventing encephalopathy is limited.
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| ===Treating underlying causes===
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| Alcoholic cirrhosis caused by alcohol abuse is treated by abstaining from alcohol. Treatment for hepatitis-related cirrhosis involves medications used to treat the different types of hepatitis, such as interferon for viral hepatitis and corticosteroids for autoimmune hepatitis. Cirrhosis caused by [[Wilson's disease]], in which copper builds up in organs, is treated with [[chelation therapy]] (e.g. [[penicillamine]]) to remove the copper.
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| ===Preventing further liver damage===
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| Regardless of underlying cause of cirrhosis, alcohol and [[acetaminophen]], as well as other potentially damaging substances, are discouraged. Vaccination of susceptible patients should be considered for [[Hepatitis A]] and [[Hepatitis B]].
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| === Chronic Pharmacotherapies ===
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| ==== Varices ====
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| * Endoscopic screening in all cirrhotic patients
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| * If varices present--treat with propranolol or nadolol
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| ==== Hepatocellular Cancer ====
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| * Incidence 1-6%/year in HCV-, HBV-, EtOH-related cirrhosis
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| * Screening frequency & benefit controversial
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| * Serum alpha-fetoprotein (AFP) every 6 months (~60% sensitive, ~90% specific)
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| * Ultrasound every 6 months (~75% sensitive, ~90% specific)
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| ===Preventing complications===
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| ====Ascites====
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| {{main|Ascites}}
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| Salt restriction is often necessary, as cirrhosis leads to accumulation of salt (sodium retention). [[Diuretic]]s may be necessary to suppress [[ascites]].
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| ====Esophageal variceal bleeding====
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| {{main|Esophageal varices}}
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| For portal hypertension, [[propranolol]] is a commonly used agent to lower blood pressure over the portal system. In severe complications from portal hypertension, [[transjugular intrahepatic portosystemic shunt]]ing is occasionally indicated to relieve pressure on the portal vein. As this can worsen encephalopathy, it is reserved for those at low risk of encephalopathy, and is generally regarded only as a bridge to liver transplantation or as a palliative measure.
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| ====Hepatic encephalopathy====
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| {{main|Hepatic encephalopathy}}
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| High-protein food increases the [[Blood urea nitrogen|nitrogen balance]], and would theoretically increase [[encephalopathy]]; in the past, this was therefore eliminated as much as possible from the diet. Recent studies show that this assumption was incorrect, and high-protein foods are even ''encouraged'' to maintain adequate nutrition.
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| ====Hepatorenal syndrome====
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| {{main|Hepatorenal syndrome}}
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| The [[hepatorenal syndrome]] is defined as a urine sodium less than 10 mmol/L and a [[serum creatinine]] > 1.5 mg/dl (or 24 hour [[creatinine clearance]] less than 40 ml/min) after a trial of volume expansion without diuretics.<ref name="pmid3297907">{{cite journal |author=Ginés P, Arroyo V, Quintero E, ''et al'' |title=Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study |journal=Gastroenterology |volume=93 |issue=2 |pages=234-41 |year=1987 |pmid=3297907 |doi=}}</ref>
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| ====Spontaneous bacterial peritonitis====
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| {{main|Spontaneous bacterial peritonitis}}
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| Cirrhotic patients with [[ascites]] are at risk of [[spontaneous bacterial peritonitis]].
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| ===Transplantation===
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| {{main|Liver transplantation}}
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| If complications cannot be controlled or when the liver ceases functioning, [[liver transplantation]] is necessary. Survival from liver transplantation has been improving over the 1990s, and the five-year survival rate is now around 80%, depending largely on the severity of disease and other medical problems in the recipient.<ref> [http://www.emedicinehealth.com/liver_transplant/page11_em.htm E-medicine liver transplant outlook and survival rates]</ref> In the United States, the [[Model for End-Stage Liver Disease|MELD score]] ([http://www.unos.org/resources/meldPeldCalculator.asp online calculator])<ref name="pmid2682175">{{cite journal |author=Cosby RL, Yee B, Schrier RW |title=New classification with prognostic value in cirrhotic patients |journal=Mineral and electrolyte metabolism |volume=15 |issue=5 |pages=261-6 |year=1989 |pmid=2682175 |doi=}}</ref> is used to prioritize patients for transplantation. Transplantation necessitates the use of immune suppressants ([[ciclosporin]] or [[tacrolimus]]).
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| ===Decompensated cirrhosis===
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| In patients with previously stable cirrhosis, decompensation may occur due to various causes, such as [[constipation]], [[infection]] (of any source), increased alcohol intake, [[medication]], bleeding from esophageal varices or dehydration. It may take the form of any of the complications of cirrhosis listed above.
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| Patients with decompensated cirrhosis generally require admission to [[hospital]], with close monitoring of the [[fluid balance]], mental status, and emphasis on adequate nutrition and medical treatment - often with [[diuretic]]s, [[antibiotic]]s, [[laxative]]s and/or [[enema]]s, [[thiamine]] and occasionally [[glucocorticoid|steroids]], [[acetylcysteine]] and [[pentoxifylline]]. Administration of [[Saline (medicine)|saline]] is generally avoided as it would add to the already high total body sodium content that typically occurs in cirrhosis.
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| == Primary Prevention ==
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| * Education about hepatotoxins:
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| *:* EtOH
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| *:* Acetaminophen
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| *:* Herbals
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| * Maintenance of adequate caloric intake: 2000-3000 kcal/d
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| * Hepatitis A Virus vaccination, Pneumovax
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| ==References==
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| {{Reflist|2}}
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| ==External links==
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| *[http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/ Cirrhosis of the Liver] at the National Digestive Diseases Information Clearinghouse (NDDIC). NIH Publication No. 04-1134, December 2003.
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| *[http://www.nlm.nih.gov/medlineplus/cirrhosis.html] at the National Library of Medicine and the National Institutes of Health. Medline Plus: Cirrhosis -- also called: Hepatic fibrosis
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| {{Gastroenterology}} | | {{Gastroenterology}} |
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| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
| [[Category:Hepatology]] | | [[Category:Hepatology]] |
| [[Category:Alcohol abuse]] | | [[Category:Disease]] |
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| [[zh-min-nan:Koaⁿ-ngē-hoà]] | | [[zh-min-nan:Koaⁿ-ngē-hoà]] |
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