60-year-old with a distended abdomen
Patient will present as → a 63-year-old white male with concern for weight gain, abdominal distension, and breast enlargement. Physical exam reveals an overweight male with bilateral gynecomastia and a distended abdomen with evidence of shifting dullness. You also note several skin lesions seen here. The patient has a past medical history of recurrent gout and Wernicke encephalopathy.
Cirrhosis is a late stage of hepatic fibrosis that has resulted in widespread distortion of normal hepatic architecture
- Characterized by regenerative nodules surrounded by dense fibrotic tissue
- The liver unable to regenerate due to large amounts of scar tissue
Cirrhosis is a leading cause of death worldwide and is the 9th leading cause of death among U.S. adults, Chronic hepatitis most common cause of cirrhosis
- Chronic hepatitis C (26%)
- Alcohol abuse (21%)
- Hepatitis C with alcoholic liver disease (15%)
- Nonalcoholic steatohepatitis/obesity (~10%)
- Hepatitis B + hepatitis D infection (15%)
- WILSON'S DISEASE: ↑ Copper, ↓ Ceruloplasmin + family history
Physical exam may be normal until end-stage disease:
- Hepatomegaly (small, fibrotic liver in end-stage disease)
- Terry’s nails (white nail beds)
- Splenomegaly (if portal hypertension)
- Central obesity
- Abdominal fluid wave, shifting dullness (ascites)
- esophageal varices
- pulmonary edema/effusion
Classical skin changes: spider angiomata, palmar erythema, jaundice, scleral icterus, ecchymoses, caput medusae, hyperpigmentation
- Asterixis (flapping tremor), dysarthria, delirium, coma
- Elevated ammonia level; BUN, sodium, and potassium
- α-fetoprotein level at diagnosis to screen for hepatocellular carcinoma (HCC)
- Abdominal ultrasound every 6–12 months to screen for hepatocellular carcinoma
- Doppler ultrasound of hepatic/portal veins
- MRI best follow-up test for HCC if α-fetoprotein elevated and/or liver mass found on ultrasound
- Noninvasive modalities, such as elastography, are being researched as an alternative to liver biopsy
- Check abdominal ultrasound every 6 months for early detection of hepatocellular carcinoma.
- Update necessary immunizations and focus on treatment of the underlying cause of cirrhosis (hepatitis C; alcohol abuse, etc.).
- Fever and abdominal pain in a patient with cirrhosis think spontaneous bacterial peritonitis
- Hepatocellular carcinoma: Monitor AFP
- Budd Chiari (hepatic vein thrombosis) triad of abdominal pain, ascites and hepatomegaly
Labs: typically AST > ALT, ↑ risk for hepatocellular carcinoma: monitor AFP
- Aspartate aminotransferase/alanine aminotransferase (AST/ALT): mildly elevated; typically AST > ALT; enzymes normalize as cirrhosis progresses
- Elevated alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), and total/direct bilirubin indicates cholestasis
- Anemia from hemolysis, folate deficiency, and splenomegaly
- Decreased platelet count from portal hypertension with splenomegaly
- Impaired synthetic liver function
- Low albumin and cholesterol
- Prolonged prothrombin (PT), international normalized ratio (INR), partial thromboplastin time (PTT). Vitamin K–dependent clotting factors
Ultrasound: helpful to determine liver size and evaluate for hepatocellular carcinoma
Liver biopsy is often required for definitive diagnosis
Treatment: Avoid alcohol, restrict salt, liver transplant
- Encephalopathy: Lactulose + neomycin
- Ascites: Sodium restriction, paracentesis
- Pruritus: Cholestyramine for pruritus
Spontaneous bacterial peritonitis is suspected in cases of unexplained fever and abdominal pain
Lactulose, a nonabsorbable synthetic disaccharide syrup, is digested by bacteria in the colon to short-chain fatty acids, resulting in acidification of colon contents. This acidification favors the formation of ammonium ion in the NH4+ ↔NH3+H+ equation; NH4+ is not absorbable, whereas NH3 is absorbable and thought to be neurotoxic. Lactulose also leads to a change in bowel flora so that fewer ammonia-forming organisms are present. Lactulose will also stop the constipation which precipitated the hepatic encephalopathy.
Rifaximin, a nonabsorbable oral antibiotic is used to control ammonia-producing intestinal flora. It has been shown as well to maintain remission from and reduce the risk of re-hospitalization for hepatic encephalopathy.
Flumazenil is used to lower blood ammonia levels.
a, c, and d
Patient with liver abscess will have same symptoms and fever. Alcohol ingestion is not a risk factor for abscess.
Hepatic encephalopathy is a complication of cirrhosis. Patient would have presented with altered sleep pattern, mental confusion, drowsiness.
Acute viral hepatitis
Patient with acute viral hepatitis may present with the same symptoms and hepatomegaly, but not ascites, gynecomastia, spider angioma, distended abdominal veins.
cessation of alcohol use
maintenance of proper nutrition
all of the above
Alcoholic liver disease
is a common cause of liver cirrhosis in the United States (21%).
Chronic hepatitis C infection
is a common cause of liver cirrhosis in the United States (26%).
Nonalcoholic fatty liver disease
is a common cause of liver cirrhosis in the United States (18%).
Spider angioma is an abnormal collection of blood vessels near the surface of the skin.
Palmar erythema is a reddening of the skin on the palmar aspect of the hands, usually over the hypothenar eminence. It may also involve the thenar eminence and fingers. It can also be found on the soles of the feet, when it is termed plantar erythema.
The yellowing of the "white of the eye" is thus more properly termed conjunctival icterus. The term "icterus" itself is sometimes incorrectly used to refer to jaundice that is noted in the sclera of the eyes, however its more common and more correct meaning is entirely synonymous with jaundice.