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Hello everyone. We are the University of Aberdeen Diagnostic Society and welcome to this talk on liver cirrhosis. This is one of the talks created as part of the MLA Teaching series co organized with Ir Juniors. In this presentation, we will go over the main clinical findings, investigations and management of liver cirrhosis. We will also be covering a case based discussion. We'll start off with a case presentation. A 50 year old man presents to emergency department with hematemesis involving a large volume of blood. He has a history of liver cirrhosis and alcohol abuse on examination. He is confused jaundice and he has a BP of 80/60 a pulse rate of 100. In terms of differential diagnosis, this presentation would most likely be fed with a ruptured esophageal or gastric varices on a background of alcoholic liver disease. An actively bleeding peptic ulcer is another differential that could have a similar presentation. Generally, peptic ulcer disease is a common finding in patients with liver cirrhosis due to the high intake of alcohol which damages the gastric mucosa. A maori v tear usually presents with a small amount of hematemesis often preceded by forceful wrenching. However, it is usually self-limiting. In this case, the patient shows signs of significant blood loss, evidenced by the low BP and hypokalemia. So less likely to be the cause of this patient's presentation. Similarly, esophagitis often presents with the coffee ground vomiting, so old coagulated blood rather than fresh blood. Therefore, this is also less likely to be the cause of the patient's bleeding. Let's discuss in more detail about what causes liver cirrhosis and the associated risk factors. Any chronic liver injury can lead to cirrhosis, hepatic cirrhosis is caused primarily by the activation of hepatic stellate cells leading to the accumulation of collagen and subsequent fibrosis. This leads to changes in the metabolism and vasculature resulting in portal hypertension and the formation of gastroesophageal viruses. The associated risk factors include chronic excessive alcohol consumption, resulting in alcoholic liver disease, obesity, diabetes, hyperlipidemia and hypertension resulting in nonalcoholic liver disease factors, increasing the risk of chronic viral hepatitis such as being an IV drug user and other causes such as autoimmune diseases. Liver cirrhosis can either present acutely with hematemesis due to a ruptured gastroesophageal viruses or more chronically with a variety of clinical signs and symptoms. These symptoms include abdominal distension due to ascites, splenomegaly, jaundice and pruritus, which are all a result of the increased pressure in the portovenous system. Some of the complications that may arise from ongoing liver injury besides portal hypertension includes renal injury, hepatic encephalopathy, right-sided heart failure, and hepatocellular carcinomas. The investigations for a patient with suspected cirrhosis begins with a thorough history and examination. A range of blood tests should also be taken to determine the potential cause of the cirrhosis. These include LFTs, serum sodium and potassium and platelet count. The imaging techniques recommended by nice for investigating cirrhosis are transient elastography and acoustic radiation force impulse which are both forms of ultrasound transient elastography. Also knownn by its brand name fibroscan uses ultrasound and low frequency elastic waves to measure the elasticity of the liver as an indication of the degree of fibrosis, acoustic radiation force impulse imaging also uses ultrasound to measure the degree of liver fibrosis. The advantage of both these methods is there is no need for a liver biopsy which carries the complications of bleeding and pain. Patients with a new diagnosis of cirrhosis should also be offered an upper endoscopy to check for viruses and a liver ultrasound every six months to check for hepatocellular carcinomas. The first line management of cirrhosis is to treat the underlying cause of the liver disease and to prevent any further liver damage to avoid acute on chronic liver failure, managing the complications of cirrhosis is also important. Patients who develop complications and presents with signs of decompensated liver disease should be referred to for a liver transplant evaluation urgently. One intervention used to manage several complications of cirrhosis is transjugular intrahepatic photosystem shunts also known as tips TPS is used to treat portal hypertension using ultrasound and fluoroscopy. An artificial passage is formed between a hepatic vein and a branch of the portal vein allowing some of the portal floor to bypass the liver and therefore reducing the pressure in the portal veins. The main indications for performing tips are refractory ascites, acute recurrent viral bleeds, treating portal hypertension and B Carrie syndrome and malignant compression of hepatic or portal veins for the management of gastric esophageal viruses. He must first assess if the patient requires resuscitation. This may also include blood transfusion and the administration of tres depressin or somatostatin analogs and prophylactic antibiotics. Nice recommends after resuscitation and supportive care vaso band ligation as a primary prevention of bleeding for people with cirrhosis who have made into large esophageal viruses for the management of gastric varices. An endoscopic injection of N Butyl two cyanoacrylates can be administered. Cyanoacrylate is a substance that acts as a glue by polymerizing and solidifying within the var which helps stop the bleeding tips can also be considered if band ligation or embutal two cyanoacrylate injections fail to stop the bleeding. So if we continue with the case, from the beginning of our presentation, we have a 50 year old patient presenting to emergency department with a hematemesis involving a large volume of blood. He has a history of liver cirrhosis and alcohol abuse and is treated for ascites with diuretics and for encephalopathy with lactulose on examination. He is confused jaundice noted to have abdominal distension, splenomegaly and multiple Spider navy. He is clinically unstable with a BP of 80/60 a pulse rate of 100 investigation findings. His full blood count shows a macrocytic anemia and thrombocytopenia. His TS show elevated transaminases and raise bilirubin coagulation shows an elevated prothrombin time and ena show elevated urea, endoscopy reveals dilated veins in the lower esophagus with an active bleeding point. So therefore, the diagnosis is an upper gi bleed due to ruptured esophageal viruses. The management is fluid resuscitation, terlipressin and prophylactic antibiotics. Endoscopic band ligation is also attempted but fails to stop the bleeding. The patient then undergoes T ES with a successful outcome. In summary, in this presentation. Today, we have covered key MLA topics including alcoholic liver disease, liver failure, ascites bleeding from the upper gi tract, jaundice, organomegaly and pruritus, which are all important presentations for liver cirrhosis. The main learning points relating to this topic are the following the clinical signs and symptoms of liver cirrhosis. The main associated risk factors including prolonged alcohol consumption. IV drug use, obesity and diabetes and autoimmune conditions. The pathophysiology of liver cirrhosis which is caused primarily by the activation of hepatic stellate cells leading to the accumulation of collagen and subsequent fibrosis. The diagnosis which is primarily based on clinical findings, blood test, endoscopy and ultrasound based imaging techniques and the management of both the underlying cause and the complications of liver cirrhosis. These management methods include supportive care tips, liver transplant, endoscopic band ligation and the injection of embutal two cyanoacrylate. Thank you for listening.
