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{{Cirrhosis}}
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==Overview==
==Overview==
Cirrhosis of the [[liver]] may be classified using two classification methods based on [[etiology]] and [[morphology]]. Currently, classifying [[cirrhosis]] based on [[morphology]] is not recommended, as it requires an invasive procedure to examine the [[Gross examination|gross appearance]] of the [[liver]], and provides little diagnostic value. Classifying [[cirrhosis]] according to [[etiology]] is a more acceptable form of classification, as it may be attained through non-invasive laboratory testing, and has a higher [[Diagnosis|diagnostic]] value.


==Classification Based on Morphology==
==Classification Based On Etiology==
Cirrhosis has historically been classified upon the nodular morphology that is seen on upon the gross appearance of the liver. Accurate assessment of the liver morphology can only be obtained through [[surgery]], [[biopsy]], or [[autopsy]], therefore more recently, more non-invasive means of classifying and determining the causes of cirrhosis are used.
[[Cirrhosis]] may be classified on the basis of [[etiology]]. This is the most widely accepted method of [[classification]].
===(a) Alcoholic cirrhosis===
* Most common cause of cirrhosis
* Caused by continuous and prolonged [[alcohol abuse]]  
* According to American Academy of Family Physicians (AAFP), approximately 60-70 percent of all cases of cirrhosis are due to [[alcohol abuse]]


===Micronodular===
===(b) Post-necrotic cirrhosis===
Micronodular cirrhosis is characterized by nodules that are less than 3mm in diameter, and is caused by:
* Occurs after a massive event causes liver [[cell death]]
* [[Viral hepatitis]] is the most common cause
* Agents that are [[toxic]] to the [[liver]] may also be a cause
 
===(c) Biliary cirrhosis===
* Results from any disease that leads to [[biliary obstruction]]
* May be due to a blockage in the [[bile duct]] and [[inflammation]]
* Excess [[bile]] in the liver may cause [[Tissue (biology)|tissue]] destruction, resulting in [[jaundice]]
 
===(d) Cardiac cirrhosis===
* Caused by [[congestive heart failure]] leading to poor circulation of [[oxygenated blood]] to the [[liver]]
* Poor [[Circulatory system|circulation]] may result in liver [[cell death]], and subsequent replacement of dead [[Cells (biology)|cells]] by [[fibrous tissue]].
 
===(e) Cirrhosis due to genetic disorders===
* Caused by [[Genetic disorder|genetic disorders]] such as [[hemochromatosis]], [[Wilson's disease]], or [[alpha-1 antitrypsin deficiency]].
 
===(f) Cirrhosis due to malnutrition===
* Cirrhosis caused by various forms of [[malnutrition]], particularly chronic [[starvation]].
 
==Classification Based On Morphology==
[[Cirrhosis]] has historically been classified based upon the [[Nodule (medicine)|nodular]] morphology that is seen on upon the [[Gross examination|gross appearance]] of the [[liver]]. Accurate assessment of the [[liver]] [[Morphology (biology)|morphology]] can only be obtained through [[surgery]], [[biopsy]], or [[autopsy]], therefore more recently, more non-invasive means of classifying and determining the causes of [[cirrhosis]] are used.
 
{| class="wikitable"
! style="background:#4479BA; color: #FFFFFF;" |Micronodular
! style="background:#4479BA; color: #FFFFFF;" |Macronodular
! style="background:#4479BA; color: #FFFFFF;" |Mixed
|-
|Micronodular [[cirrhosis]] is characterized by [[Nodule (medicine)|nodules]] that are less than 3mm in diameter
|Macronodular [[cirrhosis]] is characterized by [[Nodule (medicine)|nodules]] that are more than 3mm in diameter
|Micronodular [[cirrhosis]] can often progress into macronodular [[Cirrhosis|cirrhosis.]] During this transformation, a mixed form of [[cirrhosis]] may be seen.<ref name="pmid6629323">{{cite journal| author=Fauerholdt L, Schlichting P, Christensen E, Poulsen H, Tygstrup N, Juhl E| title=Conversion of micronodular cirrhosis into macronodular cirrhosis. | journal=Hepatology | year= 1983 | volume= 3 | issue= 6 | pages= 928-31 | pmid=6629323 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6629323  }} </ref>
|-
|'''Causes:'''
*[[Alcohol]]
*[[Alcohol]]
*[[Hemochromatosis]]
*[[Hemochromatosis]]
*Cholestatic causes of cirrhosis
*[[Cholestasis|Cholestatic]] causes of [[cirrhosis]]
*Hepatic venous outflow obstruction
*[[Hepatic venous obstruction|Hepatic venous outflow obstruction]]
*Nutritional causes of cirrhosis
*[[Nutrition|Nutritional]] causes of [[cirrhosis]]
 
|
===Macronodular===
 '''Causes:'''
Macronodular cirrhosis is characterized by nodules that are more than 3mm in diameter, and can be caused by
*Chronic [[viral hepatitis]]
* Chronic [[viral hepatitis]]
*[[Hemochromatosis]]
*Hemochromatosis
*[[Wilson's disease]]
*[[Wilson's disease]]
*Post-necrotic cirrhosis
*Post-[[necrotic]] [[cirrhosis]]
|Mixed nodular [[cirrhosis]] is also seen in Indian childhood [[cirrhosis]]. <ref name="pmid47794">{{cite journal| author=Nayak NC, Ramalingaswami V| title=Indian childhood cirrhosis. | journal=Clin Gastroenterol | year= 1975 | volume= 4 | issue= 2 | pages= 333-49 | pmid=47794 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=47794  }} </ref>
|}
==Classification Based On Severity==
* [[Child-Pugh score|Child-Pugh]] scoring system is used for predicting the risk of complications and severity of cirrhosis.
* The [[Child-Pugh score|Child-Pugh]] score employs five clinical measures of [[liver]] disease. Each measure is scored 1-3, with 3 indicating most severe derangement.
{| cellpadding="3" cellspacing="0" border="1" style="border-collapse:collapse"
| bgcolor="#aaaadd" | '''Measure'''
| bgcolor="#aaaadd" | '''1 point'''
| bgcolor="#aaaadd" | '''2 points'''
| bgcolor="#aaaadd" | '''3 points'''
| bgcolor="#aaaadd" | '''units'''
|-
| ''[[Bilirubin]] (total)''
| <34.2 (<2)
| 34.2-51.3 (2-3)
| >51.3 (>3)
| μmol/l (mg/dL)
|-
| ''[[Serum albumin]]''
| >35
| 28-35
| <28
| g/L
|-
| ''[[INR]]''
| <1.7
| 1.71-2.3
| > 2.3
| ''no unit''
|-
| ''[[Ascites]]''
| None
| Suppressed with medication
| Refractory
| ''no unit''
|-
| ''[[Hepatic encephalopathy]]''
| None
| Grade I-II (or suppressed with medication)
| Grade III-IV (or refractory)
| ''no unit''
|}
* It should be noted that different textbooks and publications use different measures. Some older reference works substitute [[Prothrombin time|PT]] prolongation for [[Prothrombin time|INR]].
* If the [[Prothrombin time|PT]] is <4 seconds than control, it is assigned 1 point. 
* If the [[Prothrombin time|PT]] is 4-6 seconds over control, then it scores 2 points and if [[Prothrombin time|PT]] is >6 seconds over control, it scores 3 points. 
* In [[primary sclerosing cholangitis]] (PSC) and [[primary biliary cirrhosis]] (PBC), the [[bilirubin]] references are changed to reflect the fact that these diseases feature high [[Bilirubin|conjugated bilirubin]] levels:
** The upper limit for 1 point is 68 μmol/l (4 mg/dL) and the upper limit for 2 points is 170 μmol/l (10 mg/dL).


===Mixed===
==== Interpretation ====
It has been shown that micronodular cirrhosis can often progress into macronodular cirrhosis. During this transformation, a mixed form of cirrhosis may be seen. <ref name="pmid6629323">{{cite journal| author=Fauerholdt L, Schlichting P, Christensen E, Poulsen H, Tygstrup N, Juhl E| title=Conversion of micronodular cirrhosis into macronodular cirrhosis. | journal=Hepatology | year= 1983 | volume= 3 | issue= 6 | pages= 928-31 | pmid=6629323 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6629323  }} </ref> Mixed nodular cirrhosis is also seen in Indian childhood cirrhosis. <ref name="pmid47794">{{cite journal| author=Nayak NC, Ramalingaswami V| title=Indian childhood cirrhosis. | journal=Clin Gastroenterol | year= 1975 | volume= 4 | issue= 2 | pages= 333-49 | pmid=47794 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=47794  }} </ref>
* Chronic liver disease is classified into [[Child-Pugh score|Child-Pugh]] class A to C:
{| cellpadding="3" cellspacing="0" border="1" style="border-collapse:collapse"
| bgcolor="#aaaadd" | '''Points'''
| bgcolor="#aaaadd" | '''Class'''
| bgcolor="#aaaadd" | '''One year survival'''
| bgcolor="#aaaadd" | '''Two year survival'''
|-
| 5-6
| A (Compensated cirrhosis)
| 100%
| 85%


==Classification Based on Etiology==
|-
Cirrhosis can be classified by etiology. This is a more widely accepted method of classification.
| 7-9
===Alcoholic Cirrhosis===
| B (Failing)
This is the most common cause of cirrhosis, and is caused by continuous and prolonged alcohol abuse. The American Academy of Family Physicians estimate that 60-70 percent of all cases of cirrhosis are a result of alcohol abuse.
| 80%
===Post-Necrotic Cirrhosis===
| 60%
This type of cirrhosis occurs after a massive event causes liver cell death. [[Viral hepatitis]] is the most common cause for this type of cirrhosis. Agents that are toxic to the liver can also cause this type of cirrhosis, as well as certain types of [[carcinomas]].


===Biliary Cirrhosis===
|-
This type of cirrhosis results from any diseases that cause biliary obstruction. There is usually a blockage in the [[bile duct]] and there may also be [[inflammation]]. The excess bile in the liver causes tissue destruction. It commonly results in [[jaundice]].
| 10-15
===Cardiac Cirrhosis===
| C (Decompensated cirrhosis)
This type of cirrhosis is caused by [[congestive heart failure]] causing poor circulation of oxygenated blood to the liver. This results in liver cell death, and the subsequent replacement of dead cells by fibrous tissue.
| 45%
===Genetic Disorder===
| 35%
This is when the cirrhosis is caused by a genetic disorder such as [[hemochromatosis]], [[Wilson's disease]], or [[alpha-1 antitrypsin deficiency]].
|}
* [[Child-Pugh score|Child-Pugh scores]] may be used to predict development of complications of cirrhosis.  
* A [[Child-Pugh score|Child-Pugh]] class C indicates higher chance of developing [[bleeding]] [[varices]] than those with class A.<ref name="pmid1568779">{{cite journal |author=de Franchis R, Primignani M |title=Why do varices bleed? |journal=[[Gastroenterology Clinics of North America]] |volume=21 |issue=1 |pages=85–101 |year=1992 |pmid=1568779 |doi= |url= |accessdate=2012-09-06}}</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Gastroenterology]]
[[Category:Hepatology]]
[[Category:Disease]]
{{WS}}
{{WH}}

Latest revision as of 14:57, 26 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Charmaine Patel, M.D. [2]Sudarshana Datta, MD [3]

Overview

Cirrhosis of the liver may be classified using two classification methods based on etiology and morphology. Currently, classifying cirrhosis based on morphology is not recommended, as it requires an invasive procedure to examine the gross appearance of the liver, and provides little diagnostic value. Classifying cirrhosis according to etiology is a more acceptable form of classification, as it may be attained through non-invasive laboratory testing, and has a higher diagnostic value.

Classification Based On Etiology

Cirrhosis may be classified on the basis of etiology. This is the most widely accepted method of classification.

(a) Alcoholic cirrhosis

  • Most common cause of cirrhosis
  • Caused by continuous and prolonged alcohol abuse
  • According to American Academy of Family Physicians (AAFP), approximately 60-70 percent of all cases of cirrhosis are due to alcohol abuse

(b) Post-necrotic cirrhosis

(c) Biliary cirrhosis

(d) Cardiac cirrhosis

(e) Cirrhosis due to genetic disorders

(f) Cirrhosis due to malnutrition

Classification Based On Morphology

Cirrhosis has historically been classified based upon the nodular morphology that is seen on upon the gross appearance of the liver. Accurate assessment of the liver morphology can only be obtained through surgery, biopsy, or autopsy, therefore more recently, more non-invasive means of classifying and determining the causes of cirrhosis are used.

Micronodular Macronodular Mixed
Micronodular cirrhosis is characterized by nodules that are less than 3mm in diameter Macronodular cirrhosis is characterized by nodules that are more than 3mm in diameter Micronodular cirrhosis can often progress into macronodular cirrhosis. During this transformation, a mixed form of cirrhosis may be seen.[1]
Causes:

 Causes:

Mixed nodular cirrhosis is also seen in Indian childhood cirrhosis. [2]

Classification Based On Severity

  • Child-Pugh scoring system is used for predicting the risk of complications and severity of cirrhosis.
  • The Child-Pugh score employs five clinical measures of liver disease. Each measure is scored 1-3, with 3 indicating most severe derangement.
Measure 1 point 2 points 3 points units
Bilirubin (total) <34.2 (<2) 34.2-51.3 (2-3) >51.3 (>3) μmol/l (mg/dL)
Serum albumin >35 28-35 <28 g/L
INR <1.7 1.71-2.3 > 2.3 no unit
Ascites None Suppressed with medication Refractory no unit
Hepatic encephalopathy None Grade I-II (or suppressed with medication) Grade III-IV (or refractory) no unit
  • It should be noted that different textbooks and publications use different measures. Some older reference works substitute PT prolongation for INR.
  • If the PT is <4 seconds than control, it is assigned 1 point.
  • If the PT is 4-6 seconds over control, then it scores 2 points and if PT is >6 seconds over control, it scores 3 points.
  • In primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC), the bilirubin references are changed to reflect the fact that these diseases feature high conjugated bilirubin levels:
    • The upper limit for 1 point is 68 μmol/l (4 mg/dL) and the upper limit for 2 points is 170 μmol/l (10 mg/dL).

Interpretation

  • Chronic liver disease is classified into Child-Pugh class A to C:
Points Class One year survival Two year survival
5-6 A (Compensated cirrhosis) 100% 85%
7-9 B (Failing) 80% 60%
10-15 C (Decompensated cirrhosis) 45% 35%

References

  1. ↑ Fauerholdt L, Schlichting P, Christensen E, Poulsen H, Tygstrup N, Juhl E (1983). "Conversion of micronodular cirrhosis into macronodular cirrhosis". Hepatology. 3 (6): 928–31. PMID 6629323.
  2. ↑ Nayak NC, Ramalingaswami V (1975). "Indian childhood cirrhosis". Clin Gastroenterol. 4 (2): 333–49. PMID 47794.
  3. ↑ de Franchis R, Primignani M (1992). "Why do varices bleed?". Gastroenterology Clinics of North America. 21 (1): 85–101. PMID 1568779. |access-date= requires |url= (help)

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