358.1 🎓 醫孞生版

358.1.0.1 📌 䞀頁重點

358.1.0.1.1 Cirrhosis Overview

358.1.1 Etiology (Top Causes Globally)

  • Chronic HBV / HCV (declining with DAAs + vaccination)
  • Alcohol (ALD)
  • MASLD/MASH (rising — increasing globally)
  • Autoimmune (AIH, PBC, PSC)
  • Hereditary (Wilson, hemochromatosis, alpha-1 AT)
  • Drug-induced
  • Vascular (Budd-Chiari, congestive hepatopathy)
  • Cryptogenic

358.1.2 Pathophysiology

  • Chronic injury → hepatic stellate cell activation → collagen deposition
  • Fibrosis → nodular regeneration → cirrhosis
  • Reversibility partial early; advanced is irreversible
  • Increased portal pressure

358.1.3 Stages

Compensated: - Asymptomatic - LFT may be normal or mildly abnormal - Synthetic function preserved

Decompensated: - Jaundice - Ascites - Variceal bleeding - Hepatic encephalopathy - Coagulopathy + hypoalbuminemia

358.1.3.0.1 Diagnostic Tools

358.1.4 Lab

  • AST/ALT (often normalized in advanced)
  • ALP, GGT (cholestatic)
  • Bilirubin ↑
  • Albumin ↓
  • PT/INR ↑ (synthetic)
  • Platelets ↓ (splenomegaly)
  • AFP (HCC screening)

358.1.5 Imaging

  • Ultrasound: nodular liver, splenomegaly, ascites, vascular changes
  • CT: structural + lesions + HCC
  • MRI: liver-specific contrast
  • Transient elastography (FibroScan): stiffness
  • MR elastography: most accurate
  • Doppler: portal/hepatic vein patency

358.1.6 Biopsy

  • Less common with imaging advances
  • Useful for specific etiology workup
358.1.6.0.1 Scoring + Prognosis

358.1.7 Child-Pugh Classification (Letter A/B/C)

Variables: - Bilirubin - Albumin - INR - Ascites - Encephalopathy

Scoring: - A (5-6): well-compensated; 5-year survival 80% - B (7-9): moderate disease; 5-year 50% - C (10-15): decompensated; 5-year 30%

358.1.8 MELD Score

  • Bilirubin, INR, creatinine
  • Predicts mortality (90-day)
  • Transplant priority allocation

358.1.9 MELD-Na

  • Adds sodium
  • Better predictor for hyponatremic patients
  • Used for allocation since 2016

358.1.10 MELD 3.0

  • Adds female sex + albumin + creatinine adjustments
  • Even better discrimination (2023)
358.1.10.0.1 Portal Hypertension

358.1.11 Definition

  • HVPG (hepatic venous pressure gradient) > 5 mmHg
  • Clinically significant > 10 mmHg
  • Predicts variceal bleeding > 12 mmHg

358.1.12 Causes

Pre-Hepatic: - Portal vein thrombosis - Splenic vein thrombosis (sinistral PT) - Schistosomiasis (some areas)

Intrahepatic Pre-Sinusoidal: - Schistosomiasis (eggs in portal venules) - Primary biliary cirrhosis - Sarcoidosis

Intrahepatic Sinusoidal (Most Common): - Cirrhosis (most causes) - Acute alcoholic hepatitis

Intrahepatic Post-Sinusoidal: - Sinusoidal obstruction syndrome (SOS, VOD)

Post-Hepatic: - Budd-Chiari (hepatic vein thrombosis) - IVC obstruction - Constrictive pericarditis (cardiac) - Right HF (congestive)

358.1.13 Manifestations

  • Esophageal + gastric varices
  • Caput medusae
  • Splenomegaly + hypersplenism
  • Ascites
  • Hepatorenal physiology
  • Encephalopathy
358.1.13.0.1 Complications of Cirrhosis

358.1.14 Ascites

Pathophysiology: - Portal hypertension + splanchnic vasodilation + Na retention - ↓ Effective arterial volume - RAAS activation

Diagnosis: - US confirms - Diagnostic paracentesis: cell count + culture + chemistry + cytology + albumin - SAAG (Serum-Ascites Albumin Gradient): - ≥ 1.1 = portal hypertension-related (cirrhosis, HF, BCS, etc.) - < 1.1 = non-portal (peritoneal carcinomatosis, TB, pancreatitis) - Protein: - < 2.5 = transudate - ≥ 2.5 = exudate

Treatment: - Sodium restriction < 2 g/d - Diuretics: spironolactone (100 mg) + furosemide (40 mg) in 100:40 ratio; max 400:160 - Large-volume paracentesis (LVP): albumin 6-8 g/L removed (for > 5 L) - TIPS (transjugular intrahepatic portosystemic shunt): refractory ascites - Liver transplant for end-stage

358.1.15 Spontaneous Bacterial Peritonitis (SBP)

Definition: - Bacterial infection of ascitic fluid without source - Common in cirrhotic ascites

Diagnosis: - PMN > 250/mm³ in ascitic fluid - Positive culture (often single organism)

Pathogens: - E. coli (most) - Klebsiella - S. pneumoniae - Enterococcus

Treatment: - Empiric ceftriaxone 2 g daily × 5 days (community-acquired) - Albumin (1.5 g/kg day 1 + 1 g/kg day 3) — reduces HRS + mortality - Tailor per culture - Avoid β-blockers if hemodynamic instability

Prophylaxis: - Norfloxacin or ciprofloxacin (history of SBP, low ascitic protein, GI bleeding, advanced cirrhosis) - Indefinite for prior SBP

358.1.16 Variceal Bleeding

Risk: - HVPG > 12 mmHg - Large varices, red spots, severity of liver disease

Prevention (Primary): - Non-selective β-blocker (propranolol, nadolol, carvedilol) — small varices with high-risk features OR medium-large varices - Endoscopic variceal ligation (EVL) — alternative or combination

Acute Bleeding: - Resuscitation (cautious; avoid over-transfusion; target Hgb 7-8) - Vasoactive: octreotide (50 ÎŒg IV → 50 ÎŒg/h infusion) OR terlipressin (Europe; FDA 2022 US) - Antibiotics: ceftriaxone 1 g daily × 7 days (improves survival) - EGD within 12 hours: variceal banding - TIPS: refractory (rescue) or early in high-risk (PVT) - Balloon tamponade (Sengstaken-Blakemore) — bridge - Surgery rarely

Secondary Prevention: - β-blocker + EVL - TIPS for refractory

358.1.17 Hepatic Encephalopathy (HE)

Pathophysiology: - Ammonia + other toxins (mercaptans, amines, GABA) - Astrocyte swelling

Grading (West Haven): - Grade 0: minimal (subclinical, detected by tests) - Grade 1: mild (sleep changes, mood) - Grade 2: moderate (lethargy, confusion, asterixis) - Grade 3: severe (somnolence, disoriented) - Grade 4: coma

Precipitants: - Infections (SBP, UTI, pneumonia) - GI bleeding (protein load) - Constipation - Electrolytes (hyponatremia, hypokalemia, alkalosis) - Drugs (sedatives, opioids) - Dehydration - TIPS-related

Treatment: - Lactulose 25-50 mL TID-QID (target 2-3 soft BMs daily) - Rifaximin 550 mg BID — reduces recurrence - Treat precipitants - Protein NOT restricted (older advice — protein-energy malnutrition concerns)

358.1.18 Hepatorenal Syndrome (HRS)

Definition: - AKI in cirrhosis without other cause - Functional renal failure - See Ch332 for details

Types: - HRS-AKI (Type 1): rapid (days-weeks); often precipitated by SBP, GI bleed - HRS-NAKI: subacute (Type 2 historical)

Treatment: - Terlipressin + albumin (FDA 2022) — first FDA-approved for HRS - Norepinephrine + albumin (ICU alternative) - Liver transplant (curative) - Avoid: diuretics, NSAIDs

358.1.19 Hepatocellular Carcinoma (HCC)

Risk: - Cirrhosis (any cause) - Chronic HBV (even non-cirrhotic) - High-risk MASH

Surveillance: - US ± AFP every 6 months - For all cirrhotic + chronic HBV high-risk

Diagnosis: - Imaging (LI-RADS criteria) - Biopsy if uncertain

See Ch359 for treatment

358.1.20 Coagulopathy

  • Decreased synthesis of clotting factors
  • Decreased synthesis of natural anticoagulants
  • “Rebalanced” hemostasis
  • Bleeding + clotting both possible
  • Manage based on clinical picture
  • INR may not reflect bleeding risk

358.1.21 Hyponatremia

  • Hypervolemic hyponatremia
  • Common
  • Treatment: fluid restriction; tolvaptan (for selected)
  • AVOID rapid correction (ODS risk)

358.1.22 Hyperestrogenic State (Cirrhosis)

  • Gynecomastia
  • Spider angiomas
  • Palmar erythema
  • Testicular atrophy
  • Decreased estrogen clearance

358.1.23 Other Complications

  • Hepatopulmonary syndrome (HPS)
  • Portopulmonary hypertension (POPH)
  • Cirrhotic cardiomyopathy
  • Splenomegaly + hypersplenism (thrombocytopenia)
  • Sarcopenia + malnutrition
  • Encephalopathy
  • Bone disease (osteoporosis)
358.1.23.0.1 Liver Transplant Indications
  • See Ch358

358.1.23.1 🩺 床邊速查

  • Cirrhosis 䞻芁原因: HBV, HCV, ALD, MASLD
  • Child-Pugh A/B/C: bilirubin + albumin + INR + ascites + encephalopathy
  • MELD-Na: transplant priority + mortality
  • HVPG > 12 mmHg: variceal bleeding risk
  • SAAG ≥ 1.1: portal hypertension-related ascites
  • SBP: PMN > 250/mm³; ceftriaxone + albumin
  • Variceal bleeding: octreotide/terlipressin + ceftriaxone + EGD banding + TIPS
  • HE: lactulose + rifaximin
  • HRS: terlipressin + albumin (FDA 2022)
  • HCC surveillance: US ± AFP every 6 mo