Cirrhosis

Cirrhosis

 

Chronic liver disease is a common entity worldwide.

Epidemiology

  • Prevalence
    • Chronic viral hepatitis, a leading cause of chronic liver disease, affects >4 million people in the U.S.
    • Alcohol related liver disease results in >12,000 deaths annually in U.S.

Etiology

  • Infectious
    • Viral, parasitic, bacterial
  • Chemical/toxin
    • Alcohol, drugs (acetaminophen)
  • Autoimmune disorders
    • Autoimmune hepatitis (AIH)
  • Genetic
    • Wilson disease, hemochromatosis, alpha-1-antitrypsin deficiency

Pathophysiology

  • Chronic liver inflammation leads to an increase in interstitial fibrous tissue
  • Widespread disruption and secondary attempts at repair by the liver cause irreversible histologic changes leading to cirrhosis
  • Hyaluronic Acid
    • Unsulfated highly polymerized glycosaminoglycan
    • Endogenous ligand for toll like receptor of Kupffer cells
    • Synthesized by activated hepatic stellate cells

Clinical Presentation

  • May be asymptomatic until late in the disease
  • Hepatocellular dysfunction – jaundice, hepatomegaly
  • Portal hypertension – varices, splenomegaly, ascites, palmar erythema, spider angiomata

Diagnosis

  • Invasive – liver biopsy (histology)
    • Considered the gold standard
    • Limitations – painful, subject to sampling error (identifies hepatic disease in only 65-75%), definite morbidity (0.3%) and mortality (0.01%) and costly
  • Noninvasive – (serum testing)
    • Serum markers
      • Albumin, prothrombin time, bilirubin and platelets may be abnormal
      • Amino transferase levels do not correlate with fibrosis
    • Biomarkers
      • Multiple biomarkers exist – most have relatively low specificity and sensitivity if used alone
      • Hyaluronic acid
        • Most useful in nonalcoholic liver fibrosis
        • Negative predictive value is 93-99%
          • Excludes patients unlikely to have extensive fibrosis or cirrhosis
        • May avoid or postpone need for liver biopsy
        • Has been combined in panel testing with other markers in attempts to improve sensitivity (Fibrospect, Fibrotest, Fibrometer, Hepascore)

See Also