Cirrhosis and its Complications

Cirrhosis Liver: 2/2 (EtoH, AIH Type1 or Type 2, NAFLD, Wilsons, Hemochromatosis etc) 

  • HCC Screening: 6 monthly with USG
  • Immunization: HepA, HepB, Pneumococcal Vaccination
  • Liver Transplantation: MELD Score

  • Cirrhosis and its complications

  • Understanding Cirrhosis related pathogenesis
    • What is the Anatomy of Liver and pathogenesis of fibrosis? 
Fibrosis in Autoimmune and Cholestatic Liver Disease Best Practice & Research Clinical Gastroenterology 2011

Understanding the pathophysiology in Cirrhosis 

Compensated vs Decompensated Disease 

Appreciate the sequence of events that leads to Renal Failure in Cirrhosis 
Appreciate difference in decompensated stage in regards to "severity" of portal hypertension, and role of bacterial translocation causing "severe" splanchnic arterial vasodilatation

Talking about the Bacterial Translocation (BT) causing decompensated cirrhosis, appreciate 3 layers of normal barriers for (BT) 

Appreciate how BT is a major player in decompensated state 

Coagulopathy in Cirrhosis

How to assess the bleeding risk in patients with Cirrhosis?
DVT prophylaxis in patient with Cirrhosis?
Appreciate 3 steps of normal hemostasis steps, and pro- and Anti- hemostatic drivers in Cirrhosis

Appreciate the impact of low ADAMTS 13 and high vWF despite low platelet counts

Appreciate pro- and anti-coagulant mechanism 
Appreciate PT is not a proxy of such balance. It only reflects pro-hemostatic forces 
Note: INR was designed to monitor only the patients on vitamin K antagonists 

Appreciate pro- and anti- fibrinolytic balance 

Appreciate the balance of pro- and anti- hemostasis forces in cirrhosis and the narrow room of hemostasis

Appreciate if PT / INR does not reflect the tendency to bleed, then what may be real factors 

Renal failure and Hepatorenal Syndrome in Cirrhosis

Appreciate the types of Renal Failure in Cirrhosis - 4 Main types 
Appreciate HRS - Type 1 and HRS - Type 2 

Work up for Cirrhosis and Renal failure
  • Evaluation of Renal Function
  • Evaluation of Liver Function including EGD to screen for varices
  • Assessment of bacterial infection 
    • Bacterial Infection should be ruled out in all patient with worsening renal function
    • Leucocytosis may be absent owing to hypersplenism in patients with cirrhosis and infection
    • Diagnostic paracentesis should be performed in patients with cirrhosis
    • Blood and Urine cultures should be carried out even in the absence of obvious signs of infections
    • CXR to rule out infection
    • Reference:

Causes of Portal HTN in the absence of Cirrhosis

Appreciate the role of the following two steps in pathophysiology of portal hypertension
  1. Increased Hepatic Resistance
    • Appreciate the pathophysiology of increased hepatic resistance 
  2. Splanchnic vasodilation 
    • Appreciate the pathophysiology of Splanchnic vasodilation 

Appreciate the mechanism of Hepatic Firbogenesis 
Best Practice & Research Clinical Gastroenterology 25 (2011) 195206 

Encephalopathy in Cirrhosis 

  • Decreased first pass effect
  • decreased RES function
  • increased NH3
SBP in Cirrhosis 

Hepatopulmonary Syndrome

Journal of Hepatology 2014 vol. 61 396–407
  • How does Spiranolactone and Furosemide combination work for ascots management?