Cirrhosis refers to a progressive, diffuse, fibrosing, nodular condition that disrupts the entire normal architecture of the liver Figures 2 through 4 ; Table 1. Inferior surface of liver, biliary tree, and gallbladder gross revealing normal hepatic tissue and structure. Photographs courtesy of Henry D. Appelman, M. Any chronic insult to the liver can cause progression to cirrhosis.
Although numerous pathophysiologic mechanisms of injury exist, the final common pathway is persistent wound healing resulting in hepatic parenchymal fibrosis. In most persons, approximately 80 to 90 percent of the liver parenchyma must be destroyed before liver failure is manifested clinically.
When complications of cirrhosis occur, they typically are related to impaired hepatic function or actual physical disruption and reorganization of the liver parenchyma. Cirrhosis often is a silent disease, with most patients remaining asymptomatic until decompensation occurs. Physicians should inquire about risk factors that predispose patients to cirrhosis Figure 1.
Quantity and duration of alcohol consumption is an important factor in the early diagnosis of cirrhosis. Early and well-compensated cirrhosis can manifest as anorexia and weight loss, weakness, fatigue, and even osteoporosis as a result of vitamin D malabsorption and subsequent calcium deficiency. Decompensated disease can result in complications such as ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and variceal bleeding from portal hypertension discussed further in part II 2.
Clinical symptoms at presentation may include jaundice of the eyes or skin, pruritus, gastrointestinal bleeding, coagulopathy, increasing abdominal girth, and mental status changes. Each of these clinical findings is the result of impaired hepatocellular function with or without physical obstruction secondary to cirrhosis. Because hepatic enzyme synthesis is required for drug metabolism, heightened sensitivity and medication toxicity may occur in patients with impaired hepatic enzyme synthesis.
Physical examination of patients with cirrhosis may reveal a variety of findings that should lead to a targeted hepatic- or gastrointestinal-based work-up Table 2. Constitutional symptoms, including anorexia, fatigue, weakness, and weight loss.
Cruveilhier-Baumgarten murmur—a venous hum in patients with portal hypertension. Information from reference Most patients with cirrhosis severe enough to lead to ascites have additional stigmata of cirrhosis on physical examination. The most useful physical finding in confirming the presence of ascites is f lank dullness to percussion. When this is detected, it is helpful to determine whether it shifts with rotation of the patient shifting dullness or whether it can be percussed anteriorly.
One study found absence of f lank dullness to be the most accurate predictor against the presence of ascites; the probability of ascites without f lank dullness was less than 10 percent. Vascular spiders spider angiomata, spider telangiectasias are vascular lesions usually found on the trunk, face, and upper extremities.
Although their pathogenesis is incompletely understood, it is believed that their presence in men is associated with an increase in the estradiol to free testosterone ratio.
The number and size of vascular spiders have been shown to correlate with the severity of chronic liver disease. Patients with numerous large vascular spiders are at increased risk for variceal hemorrhage. No serologic test can diagnose cirrhosis accurately.
When a liver abnormality is suspected or identified, a liver panel, a complete blood count CBC with platelets, and a prothrombin time test should be performed. The ALT is thought to be the most cost-effective screening test for identifying metabolic or drug-induced hepatic injury, but like other liver function tests, it is of limited use in predicting degree of inflammation and of no use in estimating severity of fibrosis.
A prospective study showed a strong correlation between liver function test results elevated to greater than twice the upper limit of normal for at least six months and underlying liver disease proved by liver biopsy. If these are negative, the remaining serologic work-up should include an antinuclear antibodies test or anti—smooth muscle antibody test, or both, to evaluate for autoimmune hepatitis; and a fasting transferrin saturation level or unsaturated iron-binding capacity and ferritin level 18 to evaluate for hereditary hemochromatosis.
Although the role of A 1 AT deficiency in liver disease in adults is not clearly defined, testing is especially important in neonates with evidence of hepatic injury.
Elevated fasting transferrin saturation, unsaturated iron-binding capacity, or ferritin. Diagnosis made via contrast cholangiography, can be supported clinically by positive antimitochondrial antibody primary biliary cirrhosis or antineutrophil cytoplasmic antibody primary sclerosing cholangitis in high titers.
Information from references 14 , 15 , 18 , and Although various radiographic studies may suggest the presence of cirrhosis, no test is considered a diagnostic standard.
Abdominal ultrasonography with Doppler is a noninvasive, widely available modality that provides valuable information regarding the gross appearance of the liver and blood flow in the portal and hepatic veins in patients suspected to have cirrhosis. Ultrasonography should be the first radiographic study performed in the evaluation of cirrhosis because it is the least expensive and does not pose a radiation exposure risk or involve intravenous contrast with the potential for nephrotoxicity as does computed tomography CT.
Nodularity, irregularity, increased echogenicity, and atrophy are ultrasonographic hallmarks of cirrhosis. In advanced disease, the gross liver appears small and multinodular, ascites may be detected, and Doppler flow can be significantly decreased in the portal circulation. The discovery of hepatic nodules via ultrasonography warrants further evaluation because benign and malignant nodules can have similar ultrasonographic appearances. CT and magnetic resonance imaging MRI generally are poor at detecting morphologic changes associated with early cirrhosis, but they can accurately demonstrate nodularity and lobar atrophic and hypertrophic changes, as well as ascites and varices in advanced disease.
Although MRI sometimes differentiates among regenerating or dysplastic nodules and hepatocellular carcinoma, it is best used as a follow-up study to determine whether lesions have changed in appearance and size.
Although used rarely, magnetic resonance angiography MRA can assess portal hypertensive changes including flow volume and direction, as well as portal vein thrombosis. Referral for liver biopsy should be considered after a thorough, noninvasive serologic and radiographic evaluation has failed to confirm a diagnosis of cirrhosis; the benefit of biopsy outweighs the risk; and it is postulated that biopsy will have a favorable impact on the treatment of chronic liver disease.
The sensitivity and specificity for an accurate diagnosis of cirrhosis and its etiology range from 80 to percent, depending on the number and size of the histologic samples and on the sampling method.
Liver biopsy is performed via percutaneous, transjugular, laparoscopic, open operative, or ultrasonography- or CT-guided fine-needle approaches.
Before the procedure, a CBC with platelets and prothrombin time measurement should be obtained. Patients should be advised to refrain from consumption of aspirin and nonsteroidal anti-inflammatory drugs for seven to 10 days before the biopsy to minimize the risk of bleeding. Already a member or subscriber? Log in. Interested in AAFP membership? If you have any of these symptoms, consult your doctor as soon as possible.
The classification of liver cirrhosis is determined according to the appearance of symptoms: liver cirrhosis resulting in obvious symptoms such as jaundice, ascites accumulation of fluid in the abdomen , and hepatic encephalopathy confusion and coma is called decompensated cirrhosis, whereas liver cirrhosis that does not produce these symptoms is called compensated cirrhosis.
Liver cirrhosis is a disease which causes a hardening of the organ. Nodules and irregularities form both inside and on the outer surface of the liver; these changes can be detected through an ultrasonic examination or CT scan. Because the function of the liver only decreases gradually, liver cirrhosis often goes undetected and unnoticed. Because of this, it is important to have regular examinations. Sometimes your doctor may find that something other than cirrhosis has caused your liver to become damaged or enlarged.
Your doctor can also diagnose liver cancer based on liver biopsy results. The NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public.
Medical history Your doctor will ask about your symptoms. Your doctor will ask about your use of alcohol and over-the-counter and prescription medicines. Your doctor will ask about your history of health conditions.
Physical exam Your doctor will examine your body, use a stethoscope to listen to sounds in your abdomen , and tap or press on specific areas of your abdomen. Blood tests can also detect if you have low levels of certain substances, such as a protein called serum albumin, which is made by the liver.
A blood test may also look for signs of abnormal blood clotting, which can indicate significant liver damage. Lab Tests Online has more information on liver function tests. If your symptoms or liver function test suggest an advanced form of ARLD either alcoholic hepatitis or cirrhosis , you may need further tests.
Some scans may also measure the stiffness of the liver, which is a good indication of whether your liver is scarred. During a liver biopsy , a fine needle is inserted into your body usually between your ribs.
A small sample of liver cells is taken and sent to a laboratory to be examined under a microscope.
0コメント