CIRRHOSIS AND PORTAL HYPERTENSION Cirrhosis and Portal Hypertension Gastroenterology Teaching Project American Gastroenterological Association
WHAT IS CIRRHOSIS? What is Cirrhosis?
DEFINITION OF CIRRHOSIS Cirrhosis End stage of any chronic liver disease Characterized histologically by regenerative nodules surrounded by fibrous tissue Clinically there are two types of cirrhosis: Compensated Decompensated
GROSS IMAGE OF A NORMAL AND A CIRRHOTIC LIVER Normal Cirrhosis Irregular surface Nodules
HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVER Normal Cirrhosis Nodules surrounded by fibrous tissue
WHAT IS THE NATURAL HISTORY OF CIRRHOSIS? What is the Natural History of Cirrhosis?
NATURAL HISTORY OF CHRONIC LIVER DISEASE Natural History of Chronic Liver Disease Chronic liver disease Compensated cirrhosis Decompensated cirrhosis Death Development of complications : Variceal hemorrhage Ascites Encephalopathy Jaundice
NATURAL HISTORY OF CIRRHOSIS Development of Complications in Compensated Cirrhosis 100 80 Probability of developing event 60 40 Ascites Jaundice Encephalopathy GI hemorrhage 20 0 0 20 40 60 80 100 120 140 160 Gines et. al., Hepatology 1987; 7:122 Months
SURVIVAL TIMES IN CIRRHOSIS Decompensation Shortens Survival 100 Probability of survival 80 60 40 All patients with cirrhosis Median survival ~ 9 years 20 0 0 20 Gines et. al., Hepatology 1987;7:122 Decompensated cirrhosis 40 60 80 100 120 140 160 Months Median survival ~ 1.6 years 180
COMPLICATIONS OF CIRRHOSIS Complications of Cirrhosis Result from Portal Hypertension or Liver Insufficiency Cirrhosis Portal hypertension Liver insufficiency Variceal hemorrhage Ascites Encephalopathy Spontaneous bacterial peritonitis Hepatorenal syndrome Jaundice
MECHANISMS OF PORTAL HYPERTENSION Most complications of cirrhosis result from portal hypertension. What mechanisms lead to portal hypertension?
DIAGNOSIS OF CIRRHOSIS Cirrhosis - Diagnosis Cirrhosis is a histological diagnosis However, in patients with chronic liver disease the presence of various clinical features suggests cirrhosis The presence of these clinical features can be followed by noninvasive testing, prior to liver biopsy
DIAGNOSIS OF CIRRHOSIS CLINICAL FINDINGS In Whom Should We Suspect Cirrhosis? Any patient with chronic liver disease Chronic abnormal aminotransferases and/or alkaline phosphatase Physical exam findings Stigmata of chronic liver disease (muscle wasting, vascular spiders, palmar erythema) Palpable left lobe of the liver Small liver span Splenomegaly Signs of decompensation (jaundice, ascites, asterixis)
DIAGNOSIS OF CIRRHOSIS LABORATORY STUDIES In Whom Should We Suspect Cirrhosis? Laboratory Liver insufficiency Low albumin (< 3.8 g/dl) Prolonged prothrombin time (INR > 1.3) High bilirubin (> 1.5 mg/dl) Portal hypertension Low platelet count (< 175 x1000/µl) AST / ALT ratio > 1
MECHANISMS OF PORTAL HYPERTENSION IN CIRRHOSIS In Cirrhosis: Increased intrahepatic resistance is the initial mechanism leading to portal hypertension
DIAGNOSIS OF CIRRHOSIS IMAGING STUDIES In Whom Should We Suspect Cirrhosis? Imaging studies Liver-spleen scan Small liver, irregular uptake Splenomegaly Colloid shift to bone marrow CAT scan / Ultrasound Nodular liver Splenomegaly Venous collaterals
DIAGNOSIS OF CIRRHOSIS LIVER-SPLEEN SCAN Liver-Spleen Scan Colloid shift to bone marrow and ribs Normal Cirrhosis Small liver, irregular uptake Splenomegaly
DIAGNOSIS OF CIRRHOSIS CAT SCAN CAT Scan in Cirrhosis Liver with an irregular surface Collaterals Splenomegaly
DIAGNOSIS OF CIRRHOSIS Confirmatory Liver Biopsy Is Not Always Necessary in Cirrhosis Liver biopsy is not necessary in the presence of any of the following: Decompensated cirrhosis (variceal hemorrhage, ascites, encephalopathy) Liver-spleen and/or CAT scan diagnostic of cirrhosis Liver biopsy is not necessary for pretransplant evaluation
NORMAL VASCULAR ANATOMY OF THE LIVER Normal Vascular Anatomy Hepatic Coronary Sinusoid Liver Inferior vena cava Portal Superior mesenteric Hepatic artery Splenic Inferior mesenteric
THE NORMAL LIVER OFFERS ALMOST NO RESISTANCE TO FLOW Normal Liver Hepatic Sinusoid Liver Portal Coronary Splenic
ARCHITECTURAL LIVER DISRUPTION IS THE MAIN MECHANISM THAT LEADS TO AN INCREASED INTRAHEPATIC RESISTANCE Cirrhotic Liver Portal systemic collaterals Distorted sinusoidal architecture leads to increased resistance Portal Splenomegaly
CAUSES OF PORTAL HYPERTENSION Causes of Portal Hypertension Cirrhosis is the most common cause of portal hypertension The site of increased resistance in cirrhosis is sinusoidal Other causes of portal hypertension are classified according to the site of increased resistance
CLASSIFICATION OF PORTAL HYPERTENSION Portal Hypertension Is Classified According to the Site of Increased Resistance Type Pre-hepatic Pre-sinusoidal Sinusoidal Post-sinusoidal Post-hepatic Example Portal or splenic thrombosis Schistosomiasis Cirrhosis Veno-occlusive disease Budd-Chiari syndrome
PRE-HEPATIC PORTAL HYPERTENSION Pre-Hepatic Portal Hypertension Hepatic Portosystemic collaterals Sinusoid Liver Thrombus Portal Splenomegaly
SINUSOIDAL PORTAL HYPERTENSION Sinusoidal Portal Hypertension Portal systemic collaterals Cirrhotic liver Portal Splenomegaly
POST-SINUSOIDAL PORTAL HYPERTENSION Post-Sinusoidal Portal Hypertension Portosystemic collaterals Sinusoid Centrilobular fibrosis Liver Portal Splenomegaly
POST-HEPATIC PORTAL HYPERTENSION Post-hepatic Portal Hypertension Thrombus Sinusoid Liver Portal Splenic