Liver Diseases - Cirrhosis and Portal Hypertension

Cirrhosis

Cirrhosis is a late stage of progressive fibrosis/scarring within the liver that causes widespread distortion of normal hepatic architecture, interfering with function. At this stage, it is considered irreversible.

The main causes of cirrhosis:

• Hepatitis C.
• Alcoholism.
• "Nonalcoholic" liver disease.

Signs and symptoms of cirrhosis:

• anorexia, weight loss,
• fatigue, weakness,
• jaundice of skin or eyes (icterus),
• spider angiomata,
• gynecomastia, from increases in estrogen,
• ascites and splenomegaly, from portal hypertension,
• abdominal pain,
• upper GI bleeding/hematemesis,
• bruising,
• dark urine,
• diffuse pruritis (itching) due to bile salts interacting with the skin,
• muscle cramps,
• amenorrhea (non-cycling) in women,
• hypogonadism (testicular atrophy) in men,
• decease in arterial blood pressure, 
• asterixis: bilateral flapping motions of the hands--a neurological finding, and
• altered mental status.

Portal Hypertension

Many of the complications of cirrhosis are due to portal hypertension, which develops from resistance to blood flow in the liver due to the progressive fibrosis that distorts the architecture.

Complications of portal hypertension are:

• hemorrhage from esophageal varices in the lower esophagus or top of the stomach;

Esophageal varices are usually asymptomatic until they burst, resulting in painless hematemesis.

• portal hypertensive gastropathy from blood congestion in the stomach that can make the lining very friable.

Upper GI bleeding is possible, which can be misinterpreted as variceal bleeding. 

• Ascites--abdominal distension from fluid accumulation; if the fluid moves into the pleural space through defects in the diaphragm, it is called "hepatic hydrothorax."

Ascites is demonstrated by an obvious abdominal distension accompanied by a "fluid wave" (bounce back of fluid with a push on one spot).

• Spontaneous bacterial peritonitis--with the typical findings of an acute abdomen; and
• hepatorenal syndrome--kidney disease due to cirrhosis.

Pulmonary hypertension and cardiac disease can also develop.

Although portal hypertension is considered fairly "late-stage," the last step is liver failure.

Although very early cirrhosis can sometimes reverse with strict avoidance of the causative factors, most cases are irreversible, the only treatment being transplant.

In the field, the biggest challenges involve upper GI bleeding from esophageal varices or gastropathy since these will present challenges to the maintenance of the ABCs (Airway, breathing, circulation) and create hypovolemia, hypotension, hypoperfusion, and hypoxia.