Cirrhosis natural history, complications and prognosis: Difference between revisions
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==Overview== | ==Overview== | ||
Cirrhosis is an irreversible process, the course of which is highly variable | Cirrhosis is an irreversible process, the course of which is highly variable in [[Patient|patients]]. The natural history progresses in such a way that there is a lengthy stage of compensation, followed by development of complications and sequelae as a result of the cirrhosis. The devastating complications include complete [[liver failure]] or the development of [[hepatocellular carcinoma]]. Other complications include [[portal hypertension]], [[ascites]], [[jaundice]], [[itching]], [[esophageal varices]], [[spontaneous bacterial peritonitis]], [[hepatic encephalopathy]], [[hepatorenal syndrome]], [[hepatopulmonary syndrome]] and [[cardiomyopathy]]. Prognosis depends on the causes, existing complications and a variety of factors which make prediction of [[life expectancy]] questionable. There are scores which classify disease severity and to determine suitability for [[liver transplantation]] in patients. | ||
===Natural History=== | ===Natural History=== | ||
*The symptoms of cirrhosis usually develop in the fourth or fifth decade of life, and start with symptoms such as [[fever]], [[anorexia]], [[fatigue]], [[weakness]], [[nausea]], [[vomiting]], [[weight loss]] and jaundice.<ref name="pmid25203153">{{cite journal |vauthors=Sajja KC, Mohan DP, Rockey DC |title=Age and ethnicity in cirrhosis |journal=J. Investig. Med. |volume=62 |issue=7 |pages=920–6 |year=2014 |pmid=25203153 |pmc=4172494 |doi=10.1097/JIM.0000000000000106 |url=}}</ref> | *The symptoms of cirrhosis usually develop in the fourth or fifth decade of life, and start with symptoms such as [[fever]], [[anorexia]], [[fatigue]], [[weakness]], [[nausea]], [[vomiting]], [[weight loss]] and [[jaundice]].<ref name="pmid25203153">{{cite journal |vauthors=Sajja KC, Mohan DP, Rockey DC |title=Age and ethnicity in cirrhosis |journal=J. Investig. Med. |volume=62 |issue=7 |pages=920–6 |year=2014 |pmid=25203153 |pmc=4172494 |doi=10.1097/JIM.0000000000000106 |url=}}</ref> | ||
*If left untreated, patients with cirrhosis may progress to develop ascites, esophageal varices, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatopulmonary and hepatorenal syndrome. | *If left untreated, patients with cirrhosis may progress to develop [[ascites]], [[esophageal varices]], [[hepatic encephalopathy]], [[spontaneous bacterial peritonitis]], [[Hepatopulmonary syndrome|hepatopulmonary]] and [[hepatorenal syndrome]]. | ||
*The general course of cirrhosis is characterized by a long stage of compensation, which may be followed by deterioration and development of specific complications. | *The general course of cirrhosis is characterized by a long stage of compensation, which may be followed by deterioration and development of specific complications. | ||
*Life threatening complications may develop in almost any patient. Once the first complication in a patient with cirrhosis is seen, it is soon followed by numerous other complications that significantly decrease life expectancy. | *Life threatening complications may develop in almost any patient. Once the first complication in a patient with cirrhosis is seen, it is soon followed by numerous other complications that significantly decrease [[life expectancy]]. | ||
*Prediction of the exact course of the disease and generalization to the entire population is difficult. | *Prediction of the exact course of the disease and generalization to the entire population is difficult. | ||
*Several factors play a key role in determining the course of the disease: | *Several factors play a key role in determining the course of the disease: | ||
**Existing hepatic function | **Existing [[Liver|hepatic]] function | ||
**Etiology of cirrhosis | **[[Etiology]] of cirrhosis | ||
**Disease progression | **Disease progression | ||
**Development of [[hepatocellular carcinoma]] | **Development of [[hepatocellular carcinoma]] | ||
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===Decompensated Cirrhosis=== | ===Decompensated Cirrhosis=== | ||
* In patients with stable cirrhosis, decompensation may occur due to various causes: | * In patients with stable cirrhosis, [[decompensation]] may occur due to various causes: | ||
* [[constipation]] | * [[constipation]] | ||
* [[infection]] | * [[infection]] | ||
* Increased alcohol intake | * Increased [[alcohol]] intake | ||
* [[Medication|Medications]] | * [[Medication|Medications]] | ||
* Bleeding from [[esophageal varices]] or [[dehydration]] | * [[Bleeding]] from [[esophageal varices]] or [[dehydration]] | ||
* Patients with decompensated cirrhosis generally require: | * Patients with decompensated cirrhosis generally require: | ||
** Admission to the [[hospital]] | ** Admission to the [[hospital]] | ||
** Close monitoring of the [[fluid balance]], mental status | ** Close monitoring of the [[fluid balance]], [[Mental status examination|mental status]] | ||
** Emphasis on adequate nutrition | ** Emphasis on adequate [[nutrition]] | ||
** Medical treatment - with [[diuretic]]s, [[antibiotic]]s, [[laxative]]s or [[enema]]s, [[thiamine]], [[glucocorticoid|steroids]], [[acetylcysteine]] and [[pentoxifylline]]. | ** [[Therapy|Medical treatment]] - with [[diuretic]]s, [[antibiotic]]s, [[laxative]]s or [[enema]]s, [[thiamine]], [[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 | ** 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 | ||
===Complications=== | ===Complications=== | ||
*The high mortality rate associated with cirrhosis is primarily due to complications. | *The high [[mortality rate]] associated with cirrhosis is primarily due to complications. | ||
*Common complications of cirrhosis include: | *Common complications of cirrhosis include: | ||
**Complications due to [[portal hypertension]] include: | **Complications due to [[portal hypertension]] include: | ||
***[[Ascites]] : [[Ascites]] is the most common complication of cirrhosis | ***[[Ascites]] : [[Ascites]] is the most common complication of cirrhosis | ||
****Due to increased pressure, fluid leaks through the [[Circulatory system|vasculature]] into the abdominal cavity | ****Due to increased pressure, [[fluid]] leaks through the [[Circulatory system|vasculature]] into the [[abdominal cavity]] | ||
***[[Esophageal varices]]: Increased pressure in the [[portal vein]] leads to collateral portal blood flow through vessels in the [[stomach]] and [[esophagus]] | ***[[Esophageal varices]]: Increased pressure in the [[portal vein]] leads to collateral portal blood flow through [[Blood vessel|vessels]] in the [[stomach]] and [[esophagus]] | ||
***[[Portal vein thrombosis]] | ***[[Portal vein thrombosis]] | ||
***Easy [[bruising]] and [[hemorrhage|bleeding]] - due to the decreased production of [[coagulation]] factors | ***Easy [[bruising]] and [[hemorrhage|bleeding]] - due to the decreased production of [[coagulation]] factors | ||
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***has a very high mortality of over 50% | ***has a very high mortality of over 50% | ||
***arises due to decreased [[perfusion]] to the kidneys, leading to [[acute renal failure]] | ***arises due to decreased [[perfusion]] to the kidneys, leading to [[acute renal failure]] | ||
***may be masked clinically due to decreased [[muscle mass]] and [[hepatic urea]] synthesis in cirrhotic patients leading to only a small elevation of [[BUN]] and [[creatinine]] | ***may be masked clinically due to decreased [[muscle mass]] and [[Liver|hepatic]] [[urea]] [[Chemical synthesis|synthesis]] in cirrhotic patients leading to only a small elevation of [[BUN]] and [[creatinine]] | ||
***diagnosis of exclusion as causes of [[Kidney|renal]] dysfunction need to be excluded first | ***diagnosis of exclusion as causes of [[Kidney|renal]] dysfunction need to be excluded first | ||
***bears poor [[patient]] prognosis | ***bears poor [[patient]] prognosis | ||
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*****increased [[alveolar-arterial gradient]] | *****increased [[alveolar-arterial gradient]] | ||
*****intra-[[Lung|pulmonary]] [[vascular]] [[Dilation|dilations]] | *****intra-[[Lung|pulmonary]] [[vascular]] [[Dilation|dilations]] | ||
****mild [[hypoxemia]] may be present due to [[ascites]] causing increased intra-abdominal fluid pressure on the [[diaphragm]]<ref name="PHD">Rodriguez-Roisin R, Krowka MJ, Herve P, Fallon MB; ERS Task Force Pulmonary-Hepatic Vascular Disorders (PHD) Scientific Committee. Pulmonary-Hepatic vascular Disorders (PHD). ''Eur Respir J'' 2004;24:861-80. PMID 15516683.</ref> | ****mild [[hypoxemia]] may be present due to [[ascites]] causing increased intra-[[Abdomen|abdominal]] [[fluid]] [[pressure]] on the [[diaphragm]]<ref name="PHD">Rodriguez-Roisin R, Krowka MJ, Herve P, Fallon MB; ERS Task Force Pulmonary-Hepatic Vascular Disorders (PHD) Scientific Committee. Pulmonary-Hepatic vascular Disorders (PHD). ''Eur Respir J'' 2004;24:861-80. PMID 15516683.</ref> | ||
*** [[Liver|Hepatic]] [[hydrothorax]]: | *** [[Liver|Hepatic]] [[hydrothorax]]: | ||
**** intra-[[Abdomen|abdominal]] fluid may seep in through the [[Thoracic diaphragm|diaphragm]] into the [[pleural space]] leading to a [[pleural effusion]] | **** intra-[[Abdomen|abdominal]] fluid may seep in through the [[Thoracic diaphragm|diaphragm]] into the [[pleural space]] leading to a [[pleural effusion]] | ||
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===Prognosis=== | ===Prognosis=== | ||
* | *The prognosis of patients varies with existing function of the [[liver]], etiology of cirrhosis, progression of the disease, development of [[Hepatocellular carcinoma|HCC]] and ability to withstand therapy. | ||
{| | {| | ||
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* [[Azotemia]] | * [[Azotemia]] | ||
* [[Leukocytosis]] | * [[Leukocytosis]] | ||
* Unresponsive to steroid treatment | * Unresponsive to [[steroid]] treatment | ||
* Reversal portal flow on doppler USG | * Reversal [[Portal vein|portal]] flow on doppler [[Medical ultrasonography|USG]] | ||
===Scoring Systems=== | ===Scoring Systems=== | ||
Revision as of 20:46, 15 December 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shankar Kumar, M.B.B.S. [2] Aditya Govindavarjhulla, M.B.B.S. [3]
Overview
Cirrhosis is an irreversible process, the course of which is highly variable in patients. The natural history progresses in such a way that there is a lengthy stage of compensation, followed by development of complications and sequelae as a result of the cirrhosis. The devastating complications include complete liver failure or the development of hepatocellular carcinoma. Other complications include portal hypertension, ascites, jaundice, itching, esophageal varices, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome and cardiomyopathy. Prognosis depends on the causes, existing complications and a variety of factors which make prediction of life expectancy questionable. There are scores which classify disease severity and to determine suitability for liver transplantation in patients.
Natural History
- The symptoms of cirrhosis usually develop in the fourth or fifth decade of life, and start with symptoms such as fever, anorexia, fatigue, weakness, nausea, vomiting, weight loss and jaundice.[1]
- If left untreated, patients with cirrhosis may progress to develop ascites, esophageal varices, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatopulmonary and hepatorenal syndrome.
- The general course of cirrhosis is characterized by a long stage of compensation, which may be followed by deterioration and development of specific complications.
- Life threatening complications may develop in almost any patient. Once the first complication in a patient with cirrhosis is seen, it is soon followed by numerous other complications that significantly decrease life expectancy.
- Prediction of the exact course of the disease and generalization to the entire population is difficult.
- Several factors play a key role in determining the course of the disease:
- Existing hepatic function
- Etiology of cirrhosis
- Disease progression
- Development of hepatocellular carcinoma
- Ability of the patient to withstand a chosen therapeutic intervention
- Ability of the intervention to significantly improve the outcome
Decompensated Cirrhosis
- In patients with stable cirrhosis, decompensation may occur due to various causes:
- constipation
- infection
- Increased alcohol intake
- Medications
- Bleeding from esophageal varices or dehydration
- Patients with decompensated cirrhosis generally require:
- Admission to the hospital
- Close monitoring of the fluid balance, mental status
- Emphasis on adequate nutrition
- Medical treatment - with diuretics, antibiotics, laxatives or enemas, thiamine, steroids, acetylcysteine and pentoxifylline.
- Administration of saline is generally avoided as it would add to the already high total body sodium content that typically occurs in cirrhosis
Complications
- The high mortality rate associated with cirrhosis is primarily due to complications.
- Common complications of cirrhosis include:
- Complications due to portal hypertension include:
- Ascites : Ascites is the most common complication of cirrhosis
- Due to increased pressure, fluid leaks through the vasculature into the abdominal cavity
- Esophageal varices: Increased pressure in the portal vein leads to collateral portal blood flow through vessels in the stomach and esophagus
- Portal vein thrombosis
- Easy bruising and bleeding - due to the decreased production of coagulation factors
- Jaundice
- Itching (pruritus)
- Hepatic encephalopathy : due to inability of the liver to clear ammonia and related nitrogenous substances from the blood, which are carried to the brain
- The features of hepatic encephalopathy are as follows:
- Changes in sleep pattern (insomnia and hypersomnia)
- Unresponsiveness
- Forgetfulness
- Poor concentration
- asterixis
- Coma
- The features of hepatic encephalopathy are as follows:
- Sensitivity to drugs due to decreased metabolism in the liver
- Ascites : Ascites is the most common complication of cirrhosis
- Hepatocellular carcinoma is primary liver cancer and is most commonly seen in cirrhotic patients with:
- Infection: due to immune system dysfunction
- Spontaneous bacterial peritonitis:
- Infection of the fluid in the abdomen due to ascites with intestinal bacteria
- Symptoms and signs include pain, tenderness and altered mental status
- Patient may be asymptomatic in early stages
- Findings on diagnostic paracentesis such as a positive culture and/or absolute neutrophil count >250/mm3 are confirmatory
- Hepatorenal syndrome:
- has a very high mortality of over 50%
- arises due to decreased perfusion to the kidneys, leading to acute renal failure
- may be masked clinically due to decreased muscle mass and hepatic urea synthesis in cirrhotic patients leading to only a small elevation of BUN and creatinine
- diagnosis of exclusion as causes of renal dysfunction need to be excluded first
- bears poor patient prognosis
- Pulmonary diseases associated with cirrhosis include:
- Hepatopulmonary syndrome:
- Hepatic hydrothorax:
- intra-abdominal fluid may seep in through the diaphragm into the pleural space leading to a pleural effusion
- Portopulmonary hypertension:
- due to increased blood pressure over the lungs as a consequence of portal hypertension[2]
- Cardiomyopathy:
- presents with normal or increased cardiac output at rest but notably decreases in stress conditions
- Muscle cramps:
- occur due to reduction in circulating plasma volume
- Complications due to portal hypertension include:
Prognosis
- The prognosis of patients varies with existing function of the liver, etiology of cirrhosis, progression of the disease, development of HCC and ability to withstand therapy.
| Well-Compensated, no alcohol | 35% mortality at 2 years |
| Onset of Ascites | 50% mortality at 2 years |
| Variceal bleeding | 65% mortality at 1 year (35% short-term mortality) |
Poor Prognostic Factors
- Prolonged prothrombin time
- Serum Bilirubin >10 mg/dL
- Hepatic encephalopathy
- Azotemia
- Leukocytosis
- Unresponsive to steroid treatment
- Reversal portal flow on doppler USG
Scoring Systems
- Model for End-Stage Liver Disease
- Pediatric End-Stage Liver Disease
- Child-Pugh score
- Child-Turcotte classification
- The severity of cirrhosis is commonly classified with the Child-Turcotte and Child-Pugh scores. It was devised in 1964 by Child and Turcotte and modified in 1973 by Pugh et al.[3]
- The Child-Pugh score uses bilirubin, albumin, INR, presence and severity of ascites and encephalopathy to classify patients in class A, B or C types.
- Class A type has a favorable prognosis, while class C is at a high risk of death.
- Modern scores, used in the allocation of liver transplants are the Model for End-Stage Liver Disease (MELD) score and its pediatric counterpart, the Pediatric End-Stage Liver Disease (PELD) score.
References
- ↑ Sajja KC, Mohan DP, Rockey DC (2014). "Age and ethnicity in cirrhosis". J. Investig. Med. 62 (7): 920–6. doi:10.1097/JIM.0000000000000106. PMC 4172494. PMID 25203153.
- ↑ 2.0 2.1 Rodriguez-Roisin R, Krowka MJ, Herve P, Fallon MB; ERS Task Force Pulmonary-Hepatic Vascular Disorders (PHD) Scientific Committee. Pulmonary-Hepatic vascular Disorders (PHD). Eur Respir J 2004;24:861-80. PMID 15516683.
- ↑ 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.