Cirrhosis

Key features include

• Fibrosis: Accumulation of extracellular matrix components, including collagen, glycoproteins, and proteoglycans.
• Regenerative Nodules: Replacement of normal lobular architecture with structurally abnormal nodules.
• Vascular Disruption: Development of portal hypertension and altered hepatic blood flow due to increased resistance in hepatic sinusoids and compensatory vascular changes.
  
  

Major Causes of Cirrhosis

1. Alcohol-Related Liver Disease (ARLD):
   • Historically a leading cause in the developed world.
   • Chronic excessive alcohol intake damages hepatocytes and promotes fibrosis.
2. Chronic Viral Hepatitis:
   • Hepatitis C Virus (HCV):
     • Accounts for approximately 26% of cases in the U.S.
     • Can coexist with alcohol-related liver damage, compounding risk.
   • Hepatitis B Virus (HBV):
     • Particularly significant in regions with endemic infection.
     • May be exacerbated by hepatitis D coinfection.
   • Combined, viral hepatitis contributes significantly to the global cirrhosis burden.
3. Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD):
   • Formerly known as nonalcoholic fatty liver disease (NAFLD).
   • Strongly linked to obesity, diabetes, and hyperlipidemia.
   • Includes nonalcoholic steatohepatitis (NASH), a more severe form with inflammation and fibrosis.
   • Up to 10% of NASH cases may progress to cirrhosis.
4. Autoimmune Liver Diseases:
   • Conditions such as autoimmune hepatitis, primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) lead to immune-mediated liver damage and fibrosis.
     
     

Less Common Causes

1. Metabolic Disorders:
   • Hemochromatosis: Iron overload damages the liver.
   • Wilson’s Disease: Copper accumulation due to genetic defect in copper metabolism.
   • Alpha-1 Antitrypsin Deficiency: Protein misfolding leads to liver damage.
2. Biliary Obstruction:
   • Chronic obstruction from conditions like biliary atresia, mechanical obstruction, or cystic fibrosis.
3. Hepatic Venous Outflow Obstruction:
   • Includes Budd-Chiari syndrome and sinusoidal obstruction syndrome, often secondary to hypercoagulable states.
4. Drugs and Toxins:
   • Medications such as methotrexate and amiodarone can cause toxic liver injury leading to fibrosis.
5. Other Causes:
   • Intestinal Bypass Surgery: Altered bile flow contributes to liver injury in severe obesity.
   • Environmental Factors: Indian childhood cirrhosis (linked to copper poisoning, now rare).

Cryptogenic Cirrhosis

• Previously a diagnosis of exclusion, many cases are now attributed to undiagnosed MASLD.
  
  

Fibrosis and Hepatic Stellate Cell Activation

1. Fibrosis as a Wound-Healing Response:
   • Fibrosis occurs as a reparative mechanism following acute or chronic cellular injury, involving a balance between tissue repair and scar formation.
   • Over time, fibrosis becomes irreversible, evolving into cirrhosis with nodule formation.
2. Role of Hepatic Stellate Cells (HSCs):
   • The activation of HSCs is central to the fibrotic process. These cells transform into myofibroblasts, producing extracellular matrix components such as collagen types I and III.
   • Collagen deposition within the space of Disse leads to sinusoidal capillarisation, reducing permeability and impairing nutrient exchange between hepatocytes and plasma.

Portal Hypertension

1. Structural and Dynamic Components:
   • Fibrotic scarring and regenerative nodules obstruct normal hepatic blood flow, resulting in elevated portal venous pressure (portal hypertension).
   • Acute insults, such as infections, exacerbate vascular tone changes, further elevating portal pressure.
2. Clinical Implications:
   • Portal hypertension drives the development of complications such as ascites, gastro-oesophageal varices, and hepatic encephalopathy.
   • Varices typically develop when the portal pressure gradient exceeds 10 mmHg.
     
     

Metabolic and Functional Consequences

1. Vascular Dysfunction:
   • Chronic liver injury disrupts vascular homeostasis, increasing vasoconstrictor signaling (e.g., endothelin-1) and reducing vasodilators like nitric oxide.
   • Inflammation from alcohol-related injury or steatosis exacerbates vascular resistance.
2. Loss of Hepatocyte Function:
   • Hepatocyte damage reduces the liver’s capacity for essential metabolic activities, including:
     • Protein synthesis: Leading to hypoalbuminaemia and exacerbation of ascites.
     • Detoxification: Accumulation of toxins like ammonia contributes to hepatic encephalopathy.
     • Nutrient metabolism and storage: Impairments result in malnutrition and micronutrient deficiencies.
       
       

Systemic Complications

1. Sarcopenia and Frailty:
   • Cirrhosis-associated sarcopenia is caused by hypermetabolism, anorexia, and malabsorption. This condition affects up to one-third of patients and is linked to a twofold increase in mortality.
   • Risk factors for sarcopenia include older age, male sex, low BMI, and alcohol-related liver disease.
2. Immune Dysfunction:
   • Immune dysregulation increases susceptibility to bacterial, fungal, and viral infections.
   • Spontaneous bacterial peritonitis is the most common infection and is associated with a high mortality risk.
     
     

Reversibility and Irreversibility

1. Potential for Reversibility:
   • Early-stage fibrosis may improve with targeted treatments such as antiviral therapy for hepatitis or cessation of alcohol consumption.
   • Serial biopsies have shown regression of fibrosis in some cases following successful interventions.
2. Irreversible Cirrhosis:
   • Advanced cirrhosis becomes irreversible due to the deposition of elastin, a component resistant to remodeling.
   • At this stage, liver transplantation remains the only definitive treatment option.
     
     

Global Burden

• Cirrhosis ranks as the 14th most common cause of death globally, accounting for approximately 2.4% of all deaths in 2019.
• An estimated 1.5 billion individuals worldwide suffer from chronic liver diseases. The global incidence of cirrhosis and related conditions was 25.35 per 100,000 people in 2019.
• The prevalence of compensated cirrhosis globally was estimated at 112 million cases in 2017, while decompensated cirrhosis was noted in 10.6 million cases.
  
  

United States

• Cirrhosis causes around 35,000 deaths annually, making it the 9th leading cause of death in the country, responsible for 1.2% of all deaths.
• The prevalence of cirrhosis in the U.S. affects approximately 2.2 million adults, with an associated mortality rate of 21.9 per 100,000 people.
• Hospital admissions due to cirrhosis increased from 3,056 per 100,000 in 2012 to 3,757 per 100,000 in 2016.
• NAFLD and its advanced form, nonalcoholic steatohepatitis (NASH), are rising in prevalence due to increasing rates of obesity and diabetes, contributing to the future burden of cirrhosis.
  
  

United Kingdom

• Cirrhosis is a leading cause of premature mortality and years of working life lost in the UK. Alcohol misuse and metabolic dysfunction-associated steatotic liver disease (MASLD, formerly NAFLD) are key contributors.
  
  

Europe

• Cirrhosis ranks as the 4th most common cause of death in Europe, with liver transplants often performed due to viral hepatitis (21% of cases) or alcohol misuse (19%).
• Dual aetiology cirrhosis (e.g., hepatitis and alcohol misuse) represents 3% of cases.
  
  

Changing Trends

1. Declining Viral Hepatitis:
   • Vaccination programs for hepatitis B and treatment advances for hepatitis C have led to a reduced incidence of cirrhosis related to viral hepatitis.
2. Rising MASLD Prevalence:
   • MASLD has increased alongside the obesity epidemic and is expected to become the leading cause of cirrhosis and liver failure in the 21st century.
     
     

Acute Liver Failure and Fulminant Hepatic Failure (FHF)

• In the U.S., about 2,000 deaths annually are attributed to FHF. Causes include viral hepatitis (e.g., hepatitis A and B), drugs (e.g., acetaminophen), toxins (e.g., Amanita phalloides), autoimmune hepatitis, and Wilson disease.
• FHF has a mortality rate of 50-80% without liver transplantation.
  
  

Asymptomatic Cases

• In the early stages, cirrhosis may remain clinically silent, especially in compensated disease.
• Diagnosis is often incidental during routine laboratory tests or imaging, revealing mild abnormalities such as:
  • Elevated aminotransferases or gamma-glutamyl transpeptidase (GGT).
  • Enlarged liver or spleen on imaging.

Early Symptoms

• Non-specific complaints such as fatigue, weakness, anorexia, and unintentional weight loss may precede overt complications.
• Early hepatic dysfunction may manifest as:
  • Pruritus due to bile salt retention.
  • Jaundice from hyperbilirubinemia, typically appearing later.
    
    

Transition to Decompensation

• Development of specific symptoms indicates progression to decompensated cirrhosis, including:
  • Abdominal distension from ascites due to portal hypertension and hypoalbuminemia.
  • Gastrointestinal bleeding (hematemesis or melena) caused by ruptured gastro-esophageal varices.
  • Cognitive changes such as confusion or irritability from hepatic encephalopathy.
    
    

Complication-Driven Symptoms

1. Portal Hypertension:
   • Symptoms include abdominal bloating, early satiety, and signs of increased venous pressure such as variceal bleeding.
2. Hepatic Encephalopathy:
   • Patients may exhibit a range of neuropsychiatric symptoms, from sleep disturbances and mild confusion to severe lethargy or coma.
3. Systemic Symptoms:
   • Recurrent infections, easy bruising, and muscle wasting become more prominent as systemic complications arise.
4. Endocrine and Metabolic Symptoms:
   • Men may report decreased libido, infertility, and gynecomastia.
   • Women may experience menstrual irregularities or amenorrhea, especially in alcohol-related liver disease.
5. Risk Factor History:
   • A detailed history of potential risk factors such as alcohol misuse, viral hepatitis exposure, obesity, or prior blood transfusions provides critical diagnostic clues.
     
     

General Appearance

• Jaundice and scleral icterus due to hyperbilirubinemia.
• Temporal wasting or muscle wasting in advanced stages, indicating malnutrition and sarcopenia.
• Cachexia in severe cases of decompensated cirrhosis.
  
  

Skin and Nails

1. Skin Changes:
   • Spider Angiomata:
     • Vascular lesions with a central arteriole and radiating branches, commonly seen on the trunk, face, and upper limbs.
     • Believed to result from altered sex hormone metabolism.
   • Palmar Erythema:
     • Redness of the thenar and hypothenar eminences.
   • Jaundice:
     • Yellowing of the skin and mucous membranes, typically seen with serum bilirubin >3 mg/dL.
   • Ecchymoses and Easy Bruising:
     • Due to impaired coagulation factor synthesis.
2. Nail Changes:
   • Leukonychia (White Nails):
     • Associated with hypoalbuminemia.
   • Terry Nails:
     • White discoloration of the proximal two-thirds of the nail plate.
   • Clubbing:
     • Uncommon but may occur in severe or advanced cases.
       
       

Neurological Findings

• Asterixis (Flapping Tremor):
  • Bilateral, asynchronous flapping movements of outstretched, dorsiflexed hands, indicative of hepatic encephalopathy.
• Fetor Hepaticus:
  • Sweet, musty breath odor due to dimethyl sulfide accumulation, associated with portosystemic shunting.
    
    

Abdomen

1. Inspection:
   • Ascites:
     • Visible abdominal distension with a fluid wave or shifting dullness on percussion.
   • Caput Medusae:
     • Dilated abdominal wall veins radiating from the umbilicus, secondary to portal hypertension.
2. Palpation:
   • Hepatomegaly:
     • Firm, nodular liver edge, if palpable.
   • Splenomegaly:
     • Enlarged spleen due to portal hypertension.
3. Auscultation:
   • Cruveilhier-Baumgarten Murmur:
     • Venous hum heard over the epigastrium due to recanalised umbilical veins.
       
       

Chest and Endocrine Findings

1. Gynecomastia:
   • Enlargement of male breast tissue, linked to altered hormone metabolism.
2. Loss of Secondary Sexual Characteristics:
   • Reduced chest and axillary hair, testicular atrophy, and feminisation in men.
     
     

Extremities

• Peripheral Oedema:
  • Related to hypoalbuminemia and salt retention.
• Dupuytren Contracture:
  • Thickened and shortened palmar fascia causing finger flexion deformities, commonly seen in alcohol-associated cirrhosis.
    
    

Head and Neck

• Parotid Gland Enlargement:
  • Common in alcohol-related liver disease.
• Telangiectasia and Paper-Money Appearance:
  • Fine vascular networks on the face and skin, particularly in chronic alcohol-related cirrhosis.
    
    

Assessment of the Severity 

Child-Turcotte-Pugh (CTP) Scoring System

1. Overview:
   • Introduced in 1964 by Child and Turcotte for predicting operative mortality in portocaval shunt surgery.
   • Revised in 1973 by Pugh to include albumin and INR instead of nutritional status and prothrombin time.
2. Scoring Variables:
   • Encephalopathy (None, Grade 1-2, Grade 3-4).
   • Ascites (Absent, Slight, Moderate/Large).
   • Bilirubin levels:
     • General: <2 mg/dL, 2-3 mg/dL, >3 mg/dL.
     • For PBC/PSC: <4 mg/dL, 4-10 mg/dL, >10 mg/dL.
   • Albumin levels: >3.5 g/dL, 2.8-3.5 g/dL, <2.8 g/dL.
   • Prothrombin time (seconds prolonged or INR): <4 s (INR <1.7), 4-6 s (INR 1.7-2.3), >6 s (INR >2.3).
3. CTP Classes:
   • Class A (5-6 points): Well-compensated cirrhosis.
   • Class B (7-9 points): Significant functional compromise.
   • Class C (10-15 points): Decompensated cirrhosis with poor prognosis.
4. Prognosis:
   • A CTP score of 10 or higher is associated with a 50% mortality rate within 1 year.
     
     

Model for End-Stage Liver Disease (MELD) Score

1. Overview:
   • Adopted in 2002 by liver transplant programs to prioritise patients based on disease severity.
   • Score ranges from 6 to 40 and is calculated using serum bilirubin, INR, and creatinine levels.
2. MELD Score and 3-Month Mortality:
   • <9: 2.9% mortality.
   • 10-19: 7.7% mortality.
   • 20-29: 23.5% mortality.
   • 30-39: 60% mortality.
   • ≥40: 81% mortality.
     
     

First-Line Investigations

1. Liver Function Tests (LFTs):
   • Aminotransferases:
     • Elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) indicate hepatocellular damage.
     • An AST/ALT ratio ≥1 is suggestive of cirrhosis, particularly in alcohol-related liver disease.
   • Alkaline Phosphatase (ALP) and Gamma-Glutamyl Transferase (GGT):
     • Elevated in cholestasis and biliary diseases such as primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC).
   • Bilirubin:
     • Normal in compensated cirrhosis; elevated levels indicate progressive disease.
   • Albumin:
     • Decreased, reflecting reduced hepatic synthetic function.
   • Prothrombin Time (PT)/International Normalized Ratio (INR):
     • Prolonged PT indicates impaired synthesis of clotting factors.
2. Serum Electrolytes:
   • Sodium: Hyponatremia is common in patients with ascites.
   • Potassium: Hyperkalemia may occur, particularly in advanced disease.
3. Complete Blood Count (CBC):
   • Platelets: Thrombocytopenia (<150,000/μL) is an early and sensitive marker of cirrhosis due to portal hypertension and hypersplenism.
4. Serological Tests for Viral Hepatitis:
   • Hepatitis B Surface Antigen (HBsAg) and HBV DNA: Indicate chronic hepatitis B.
   • Anti-HCV Antibodies and HCV RNA: Confirm chronic hepatitis C infection.
     
     

Investigations to Consider for Specific Causes

1. Iron Studies (e.g., Serum Ferritin, Transferrin Saturation):
   • Elevated levels suggest hemochromatosis; HFE genetic testing may be required.
2. Autoimmune Markers:
   • Antinuclear Antibodies (ANA), Anti-Smooth Muscle Antibodies (ASMA), and Liver Kidney Microsomal Antibodies (Anti-LKM): Indicative of autoimmune hepatitis.
   • Antimitochondrial Antibodies (AMA): Diagnostic of PBC.
3. Copper and Ceruloplasmin Levels:
   • Low ceruloplasmin and elevated urinary copper suggest Wilson's disease.
4. Alpha-1 Antitrypsin Levels:
   • Reduced levels may indicate alpha-1 antitrypsin deficiency.
5. Alpha-Fetoprotein (AFP):
   • Elevated levels suggest hepatocellular carcinoma (HCC); cross-sectional imaging is required for confirmation.
     
     

Imaging Studies

1. Ultrasound:
   • Detects liver surface nodularity, caudate lobe hypertrophy, splenomegaly, ascites, and portal vein dilatation.
   • Duplex Doppler ultrasonography assesses blood flow in the portal vein and identifies thrombosis.
2. CT and MRI:
   • Provide detailed views of liver morphology, nodularity, and signs of portal hypertension (e.g., collateral circulation, varices).
   • MRI with contrast is particularly useful for diagnosing HCC.
3. Transient Elastography (FibroScan):
   • Non-invasive assessment of liver stiffness, useful for staging fibrosis and detecting cirrhosis.

Endoscopy

• Upper Gastrointestinal Endoscopy:
  • Evaluates for gastro-esophageal varices and portal hypertensive gastropathy.
  • Baveno VII criteria guide when to perform screening endoscopy.
    
    

Liver Biopsy

• While invasive, liver biopsy remains the gold standard for diagnosing cirrhosis when non-invasive methods are inconclusive.
• Histological findings include fibrosis, architectural distortion, and regenerative nodules.
  
  

Vascular Disorders

1. Budd-Chiari Syndrome:
   • Signs/Symptoms: Abdominal pain, diarrhea, and progressively worsening ascites.
   • Investigations:
     • Doppler ultrasound and abdominal CT: Absence of hepatic vein filling.
     • CT: Rapid contrast clearance in the caudate lobe.
2. Portal Vein Thrombosis:
   • Signs/Symptoms: Abdominal pain and features of underlying causes such as pancreatitis or cholangitis.
   • Investigations:
     • Doppler ultrasound and CT: Portal vein filling defect or absence of flow.
     • Magnetic resonance angiography: Normal hepatic venous pressure gradient.
3. Splenic Vein Thrombosis:
   • Signs/Symptoms: Severe abdominal pain, vomiting, and signs of pancreatitis.
   • Investigations:
     • Ultrasound and CT: Evidence of splenic vein thrombosis.
     • Magnetic resonance angiography: Normal hepatic venous pressure gradient.
4. Idiopathic Portal Hypertension (Hepatoportal Sclerosis):
   • Signs/Symptoms: Typically asymptomatic with no distinct clinical features.
   • Investigations: Liver biopsy revealing no evidence of cirrhosis.
5. Inferior Vena Cava Obstruction:
   • Signs/Symptoms: Features of renal cell carcinoma, including hematuria, flank pain, abdominal mass, weight loss, and hypertension.
   • Investigations: Abdominal ultrasound and CT showing obstruction.
     
     

Infectious and Parasitic Disorders

1. Schistosomiasis:
   • Signs/Symptoms: Travel to endemic regions, febrile illness, weight loss, urticarial rash, lymphadenopathy.
   • Investigations: Magnetic resonance angiography shows normal hepatic venous pressure gradient.
     
     

Granulomatous Disorders

1. Sarcoidosis:
   • Signs/Symptoms:
     • Pulmonary involvement: Dry cough and dyspnea.
     • Cutaneous involvement: Maculopapular lesions, erythema nodosum.
     • Ocular involvement: Uveitis, sicca syndrome, glaucoma.
   • Investigations:
     • Liver biopsy: Non-necrotizing granulomas.
     • Chest X-ray: Hilar lymphadenopathy and parenchymal disease.
       
       

Toxicities and Metabolic Conditions

1. Vitamin A Intoxication:
   • Signs/Symptoms: No specific clinical signs; history of excessive vitamin A intake.
   • Investigations: Correlate with history and liver biopsy findings.
2. Arsenic and Vinyl Chloride Toxicity:
   • Signs/Symptoms: Exposure history with non-specific systemic complaints.
   • Investigations: Supported by toxicological history.
3. Metabolic and Genetic Disorders:
   • Conditions: Tyrosinemia, galactosemia, neonatal iron storage diseases, Wilson disease, hemochromatosis, alpha-1 antitrypsin deficiency.
   • Investigations: Condition-specific tests such as ceruloplasmin levels, transferrin saturation, and genetic studies.

Pregnancy-Associated and Toxin-Induced Liver Injury

1. Acute Fatty Liver of Pregnancy (AFLP):
   • Signs/Symptoms: Sudden onset of nausea, vomiting, abdominal pain, jaundice in late pregnancy.
   • Investigations: Elevated liver enzymes, bilirubin, and coagulopathy.
2. Drug or Toxin Exposure:
   • Examples: Acetaminophen overdose, Amanita phalloides mushroom poisoning.
   • Signs/Symptoms: Rapid onset liver failure, jaundice, and coagulopathy.
   • Investigations: History of exposure and elevated liver enzymes.
     
     

Treating the Underlying Cause

• Chronic Hepatitis C:
  • Direct-acting antivirals (DAAs) are the cornerstone of therapy. Regimens are tailored to the viral genotype and the presence or absence of cirrhosis.
  • Early treatment has been shown to reduce the risk of hepatocellular carcinoma (HCC), liver decompensation, and mortality.
• Chronic Hepatitis B:
  • Antiviral therapies such as nucleos(t)ide analogs (e.g., entecavir, tenofovir) suppress viral replication and reduce disease progression.
• Alcohol-Related Liver Disease:
  • Complete abstinence is critical and often requires a multidisciplinary approach involving addiction specialists and support programs.
  • Corticosteroids or pentoxifylline may be used in severe alcoholic hepatitis.
• Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD):
  • Weight loss of at least 7-10% improves steatosis and fibrosis.
  • Control of metabolic risk factors such as diabetes and hyperlipidemia with pharmacological and non-pharmacological interventions.
    
    

Prevention of Hepatic Insults

• Vaccination:
  • Immunisation against hepatitis A and B for those who are not immune.
• Hepatotoxins:
  • Avoid alcohol and drugs such as NSAIDs, aminoglycosides, and high doses of paracetamol (>2-3 g/day).
• Diet and Nutrition:
  • Provide moderate sodium restriction (no-added-salt diet) for patients with ascites.
  • Avoid excessive fasting by recommending small frequent meals and a bedtime snack to prevent catabolism.
  • Protein intake of 1.2–1.5 g/kg/day is recommended for those with sarcopenia.
    
    

Monitoring and Surveillance

• Complications:
  • Periodic evaluations for the development of ascites, variceal bleeding, hepatic encephalopathy, and hepatorenal syndrome.
• Hepatocellular Carcinoma (HCC):
  • Six-monthly surveillance with abdominal ultrasound and alpha-fetoprotein (AFP) measurement.
  • Additional imaging (e.g., MRI or CT) may be warranted in high-risk cases.
• Portal Hypertension:
  • Screening endoscopy to detect gastro-esophageal varices at the time of cirrhosis diagnosis.
  • Use transient elastography and platelet count to stratify the risk of varices when endoscopy is unavailable.

Managing Complications

1. Ascites:
   • Managed initially with spironolactone (100–400 mg/day) and furosemide (up to 160 mg/day).
   • Refractory cases may require large-volume paracentesis with albumin infusion (6–8 g per liter of fluid removed).
   • Transjugular intrahepatic portosystemic shunt (TIPS) is considered for patients with refractory ascites or recurrent pleural effusions.
2. Gastro-Oesophageal Varices:
   • Primary Prophylaxis: Non-selective beta-blockers (e.g., carvedilol or propranolol) or endoscopic variceal ligation (EVL) for medium or large varices.
   • Acute Bleeding: Treated as an emergency with fluid resuscitation, vasopressors (e.g., terlipressin), and endoscopic interventions (e.g., EVL or sclerotherapy).
   • Short-term antibiotics (e.g., ceftriaxone) are used to prevent infection in cases of variceal bleeding.
3. Hepatic Encephalopathy:
   • Treat with lactulose (to achieve 2–3 soft stools per day) and rifaximin.
   • Identify and correct precipitating factors such as infection, electrolyte disturbances, or gastrointestinal bleeding.
4. Spontaneous Bacterial Peritonitis (SBP):
   • Diagnosed via ascitic fluid analysis (neutrophil count >250 cells/mm³).
   • Managed with intravenous antibiotics (e.g., cefotaxime) and albumin infusion (1.5 g/kg on day 1, 1 g/kg on day 3).
   • Prophylactic antibiotics are recommended for high-risk patients (e.g., those with low ascitic protein <10 g/L or prior SBP episodes).
5. Hepatorenal Syndrome (HRS):
   • Managed with vasoconstrictors (e.g., terlipressin) and albumin infusion.
   • Midodrine with octreotide may be used when terlipressin is unavailable.
6. Malnutrition and Sarcopenia:
   • Early nutritional assessment and intervention are crucial, including oral or enteral supplementation.
   • Protein restriction is not recommended, even in hepatic encephalopathy.
     
     

Liver Transplantation

• Patients with decompensated cirrhosis or complications like HCC, refractory ascites, or hepatic encephalopathy should be referred for transplant evaluation.
• MELD and MELD-Na scores are used to prioritise patients based on mortality risk.
• Pre-transplant optimisation includes addressing sarcopenia and controlling complications.
  
  

Palliative Care

• Essential for managing symptoms in advanced cirrhosis, such as pain, fatigue, dyspnea, and anxiety.
• Tailored interventions may include paracentesis for refractory ascites, pleural drainage for hepatic hydrothorax, and psychological support.
  
  

Overall Prognosis

1. Median Survival:
   • Patients with compensated cirrhosis: Median survival >10 years.
   • Patients with decompensated cirrhosis: Median survival ~2 years.
2. Compensated Cirrhosis:
   • 10-year survival rate: ~90%.
   • Risk of transitioning to decompensated cirrhosis within 10 years: ~50%.
3. Decompensated Cirrhosis:
   • Associated with high mortality rates, particularly following complications:
     • Ascites: Median survival ~1.1 years.
     • Hepatic encephalopathy: Median survival ~0.92 years.
     • Gastrointestinal bleeding: 1-year mortality ~57%.
4. COVID-19 Impact:
   • Mortality is higher in patients with cirrhosis who contract COVID-19, especially in advanced stages of liver disease.

Stages of Cirrhosis

• Stage 1: No varices or ascites; annual mortality ~1%.
• Stage 2: Presence of varices without bleeding; annual mortality ~4%.
• Stage 3: Presence of ascites (± varices); annual mortality ~20%.
• Stage 4: Gastrointestinal bleeding due to portal hypertension (± ascites); 1-year mortality ~57%.
  
  

Predictive Models for Cirrhosis Prognosis

1. Child-Turcotte-Pugh (CTP) Classification:
   • Variables: Serum albumin, bilirubin, prothrombin time (PT/INR), ascites, and hepatic encephalopathy.
   • Classification:
     • Class A (5-6 points): Well-compensated; 1-year survival ~100%.
     • Class B (7-9 points): Moderate functional impairment; 1-year survival ~80%.
     • Class C (10-15 points): Decompensated; 1-year survival ~45%.
   • Surgical Risk:
     • Mortality increases with higher CTP classes: ~10% for Class A, 30% for Class B, and 82% for Class C during abdominal surgeries.
2. Model for End-Stage Liver Disease (MELD) Score:
   • Variables: Serum bilirubin, creatinine, and INR.
   • Predicts 3-month mortality risk:
     • MELD <9: 2.9% mortality.
     • MELD 10-19: 7.7% mortality.
     • MELD 20-29: 23.5% mortality.
     • MELD 30-39: 60% mortality.
     • MELD ≥40: 81% mortality.
   • Utilised for prioritising liver transplantation.
3. Factors Worsening Prognosis:
   • Low Mean Arterial Pressure (≤82 mmHg):
     • 2-year survival ~20%; 4-year survival 0%.
   • Relative Adrenal Insufficiency:
     • Associated with higher rates of infections, sepsis, hepatorenal syndrome, and death.
   • Severe Septic Shock:
     • Requires aggressive treatment, including glucocorticoid therapy in some cases.
       
       

Impact of Liver Transplantation

• Survival Rates Post-Transplant:
  • 1-year survival: ~85%.
  • 5-year survival: ~72%.
• Challenges:
  • Recurrence of the underlying liver disease.
  • Long-term complications of immunosuppressive therapy, such as infection and metabolic disorders.
    
    

Prognosis with Complications

1. Acute-on-Chronic Liver Failure (ACLF):
   • High short-term mortality, requiring intensive care and early liver transplantation in selected cases.
2. Hepatorenal Syndrome (HRS):
   • Rapidly progressive with poor outcomes without vasoconstrictor therapy and liver transplantation.
3. Hepatopulmonary Syndrome:
   • Associated with dyspnea and hypoxemia, often resolves post-liver transplantation.
4. Spontaneous Bacterial Peritonitis (SBP):
   • Increases the risk of hepatorenal syndrome and death, particularly in the absence of early antibiotic therapy.
     
     

Ascites

• Overview:
  • The most common complication of cirrhosis, resulting from portal hypertension and sodium retention due to renin-angiotensin-aldosterone system activation.
  • Diagnostic paracentesis is essential for new-onset ascites to evaluate cell count, albumin gradient, and cultures.
• Management:
  • Moderate sodium restriction (daily intake <6.5 g) and spironolactone, with or without furosemide.
  • Avoid nephrotoxic drugs (e.g., NSAIDs, ACE inhibitors).
  • Refractory ascites: Managed with large-volume paracentesis and albumin replacement or transjugular intrahepatic portosystemic shunt (TIPS).
  • Long-term abdominal drains may be considered for palliation.
    
    

Gastro-Oesophageal Varices

• Overview:
  • Present in ~50% of cirrhosis patients; variceal bleeding has a high mortality rate (~20% at 6 weeks).
• Screening and Prevention:
  • Baseline endoscopy for all cirrhosis patients; high-risk patients (e.g., liver stiffness ≥20 kPa or platelet count ≤150 × 10⁹ cells/L) require regular monitoring.
  • Prophylaxis includes non-selective beta-blockers (e.g., carvedilol) or endoscopic variceal ligation (EVL) for medium or large varices.
• Management of Acute Bleeding:
  • Resuscitation with blood transfusion (target hemoglobin 7-8 g/dL), vasopressors (e.g., terlipressin), and urgent endoscopy for EVL or sclerotherapy.
  • Antibiotic prophylaxis (e.g., ceftriaxone) reduces infection rates and mortality.
    
    

Hepatic Encephalopathy

• Overview:
  • characterised by neuropsychiatric disturbances ranging from mild confusion to coma, often precipitated by infection, bleeding, or electrolyte imbalance.
• Management:
  • Lactulose and rifaximin to reduce ammonia levels.
  • Correction of precipitating factors (e.g., infection, electrolyte imbalance).
  • Protein restriction is not recommended.
    
    

Spontaneous Bacterial Peritonitis (SBP)

• Overview:
  • Diagnosed by an ascitic fluid neutrophil count >250 cells/mm³.
• Management:
  • Intravenous antibiotics (e.g., cefotaxime) and albumin infusion improve survival.
  • Patients with low ascitic protein (<10 g/L) should receive primary prophylaxis.

Hepatorenal Syndrome (HRS)

• Overview:
  • A functional renal failure caused by splanchnic vasodilation and renal vasoconstriction.
• Management:
  • Vasoconstrictors (e.g., terlipressin) and albumin infusion.
  • Avoid nephrotoxic agents and excessive diuresis

Hepatocellular Carcinoma (HCC)

• Increased risk in patients with hepatitis B, hepatitis C, alcohol-related liver disease, and hemochromatosis.
• Surveillance:
  • Abdominal ultrasound and alpha-fetoprotein (AFP) every 6 months.
• Management:
  • Curative options include surgical resection, liver transplantation, or ablative therapies (e.g., radiofrequency ablation).
  • Advanced disease may require systemic therapy (e.g., sorafenib).
    
    

Hepatic Hydrothorax

• Overview:
  • A pleural effusion resulting from ascitic fluid movement through diaphragmatic defects.
• Management:
  • Similar to ascites: sodium restriction, diuretics, and therapeutic thoracentesis.
    
    

Acute-on-Chronic Liver Failure (ACLF)

• Overview:
  • Severe decompensation with multi-organ failure, often triggered by infection, alcohol, or ischemia.
• Management:
  • Intensive care support and treatment of the underlying trigger.
  • Early liver transplantation in select cases.
    
    

Malnutrition and Sarcopenia

• Overview:
  • Common in cirrhosis due to reduced protein synthesis, hypermetabolism, and malabsorption.
• Management:
  • High-protein diets (1.2–1.5 g/kg/day) and dietary supplementation.
  • Avoid prolonged fasting.
    
    

Portopulmonary Hypertension and Hepatopulmonary Syndrome

• Portopulmonary Hypertension:
  • Defined by pulmonary hypertension associated with portal hypertension.
  • Vasodilators (e.g., epoprostenol) may improve symptoms; severe cases may preclude transplantation.
• Hepatopulmonary Syndrome:
  • Triad of liver disease, hypoxemia, and intrapulmonary vascular dilations.
  • Resolves with liver transplantation.
    
    

Hypogonadism and Feminization

• Overview:
  • Imbalance in estrogen and androgen levels leads to testicular atrophy, gynecomastia, and reduced libido in men.
• Management:
  • Symptomatic treatment; liver transplantation may resolve hormonal imbalances.
    
    

Bleeding and Thrombosis

• Overview:
  • Cirrhosis disrupts the balance between bleeding and clotting, increasing the risk of both.
• Management:
  • Anticoagulation for venous thromboembolism is recommended when appropriate.
  • Lusutrombopag and avatrombopag can address thrombocytopenia in preparation for procedures.
    
    

1. Asrani SK, Devarbhavi H, Eaton J, Kamath PS. Burden of liver diseases in the world. Journal of Hepatology. 2019;70(1):151-171.
2. Blachier M, Leleu H, Peck-Radosavljevic M, Valla DC, Roudot-Thoraval F. The burden of liver disease in Europe: A review of available epidemiological data. Journal of Hepatology. 2013;58(3):593-608.
3. European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines for the management of decompensated cirrhosis. Journal of Hepatology. 2018;69(2):406-460.
4. European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis. Journal of Hepatology. 2015;63(1):237-264.
5. European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines: Management of NAFLD. Journal of Hepatology. 2016;64(6):1388-1402.
6. Farrell GC, Wong VW, Chitturi S. NAFLD in Asia—As common and important as in the West. Nature Reviews Gastroenterology & Hepatology. 2013;10(5):307-318.
7. Friedman SL, Pinzani M. Hepatic fibrosis: Mechanisms and clinical implications. Nature Reviews Gastroenterology & Hepatology. 2022;19(2):77-94.
8. Friedman SL. Hepatic stellate cells: Protean, multifunctional, and enigmatic cells of the liver. Physiological Reviews. 2008;88(1):125-172.
9. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: A systematic analysis. Lancet. 2020;396(10258):1204-1222.
10. Jalan R, Hayes PC. Hepatic encephalopathy and other neuropsychiatric abnormalities in liver disease. The Lancet. 1997;350(9071):1344-1349.
11. Kondo T, Okamoto R, Kishimoto H. Prognostic implications of portal hemodynamics on Doppler ultrasonography. Hepatology International. 2016;10:454-464.
12. Naveau S, Perlemuter G, Balian A. Epidemiology and natural history of cirrhosis. La Revue du Praticien. 2005;55(14):1527-1532.
13. National Institute for Health and Care Excellence (NICE). Cirrhosis in over 16s: Assessment and management. Last updated September 2023. Available at: www.nice.org.uk.
14. Schuppan D, Afdhal NH. Liver cirrhosis. Lancet. 2008;371(9615):838-851.
15. Schuppan D, Schattenberg JM. Pathogenesis and clinical consequences of fibrosis in chronic liver diseases. Journal of Hepatology. 2013;59(5):857-868.
16. Scaglione S, Kliethermes S, Cao G, Shoham D, Durazo R, Luke A, Volk ML. The epidemiology of cirrhosis in the United States: A population-based study. Journal of Clinical Gastroenterology. 2015;49(8):690-696.
17. Tsochatzis EA, Bosch J, Burroughs AK. Liver cirrhosis. The Lancet. 2014;383(9930):1749-1761.