Understanding Major Complications of Liver Cirrhosis

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Explore the major complications of liver cirrhosis, including portal hypertension, variceal bleeding, splenomegaly, ascites, spontaneous bacterial peritonitis, jaundice, coagulopathy, hepatic encephalopathy, hepatorenal syndrome, and hepatocellular carcinoma. Learn about the pathogenetic mechanisms, clinical features, and pathological findings associated with these complications.

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Complicationsoflivercirrhosis

Complicationsoflivercirrhosis Recognizethemajorcomplicationsofcirrhosis Understandthepathogeneticmechanisms underlyingtheoccurrenceofthecomplications Recognizetheclinicalfeaturesinherenttothe abovementionedcomplications Describethepathologicalfindingsofthe differentcomplications

. Complicationsof livercirrhosis Portalhypertension Varicealbleeding Splenomegaly Ascites Spontaneousbacterialperitonitis Jaundiceandcholestasis Coagulopathy Hepaticencephalopathy Hepatorenalsyndrome Hepatocellularcarcinoma

Complicationsoflivercirrhosis PORTALHYPERTENSION:

Complicationsoflivercirrhosis PORTALHYPERTENSION: Resistancetobloodflow prehepatic,intrahepatic,andposthepatic Thedominantintrahepaticcauseiscirrhosis (Thisisaccountingformostcasesof portalhypertension) Portosystemicshuntsdevelopwhenbloodflowis reversedfromtheportaltosystemiccirculation.

Complicationsoflivercirrhosis ESOPHAGEALVARICES

Complicationsoflivercirrhosis ESOPHAGEALVARICES: Insteadofreturningdirectlytotheheart, venousbloodfromtheGItractisdeliveredto theliverviatheportalveinbeforereaching theinferiorvenacava. Thiscirculatorypatternisresponsibleforthefirst- passeffectinwhichdrugsandothermaterials absorbedintheintestinesareprocessedbytheliver beforeenteringthesystemiccirculation..

Complicationsoflivercirrhosis ESOPHAGEALVARICES: Diseasesthatimpedethisflowcauseportal hypertensionandcanleadtothedevelopment ofesophagealvarices,animportantcauseof esophagealbleeding

Complicationsoflivercirrhosis Portal Portalhypertention PortosystemicShunt PortosystemicShunt Rectum(hemorrhoids) Abdominalwallcollaterals(caputmedusae) Cardioesophagealjunction(esophagogastricvarices)

Complicationsoflivercirrhosis ESOPHAGEALVARICES: Pathogenesis Portalhypertensionresultsinthedevelopmentof collateralchannelsatsiteswheretheportaland cavalsystemscommunicate.Althoughthese collateralveinsallowsomedrainagetooccur,they leadtodevelopmentofacongestedsubepithelial andsubmucosalvenousplexuswithinthedistal esophagus.(varices):90%ofcirrhoticpatients Alcohol-Hepaticschistosomiasis

Complicationsoflivercirrhosis ESOPHAGEALVARICES Morphology: Varicescanbedetectedbyvenogram:tortuousdilatedveinslying primarilywithinthesubmucosaofthedistalesophagusand proximalstomach.Venouschannelsdirectlybeneaththe esophagealepitheliummayalsobecomemassivelydilated. Varicesmaynotbegrosslyobviousinsurgicalorpostmortem specimens,becausetheycollapseintheabsenceofbloodflow. Varicealruptureresultsinhemorrhageintothelumenor esophagealwall,inwhichcasetheoverlyingmucosaappears ulceratedandnecrotic.Ifrupturehasoccurredinthepast,venous thrombosis,inflammation,andevidenceofpriortherapymayalso bepresent.

Complicationsoflivercirrhosis ESOPHAGEALVARICES: Clinicalfeatures: Asymptomaticorrupture- massivehematemesis. Inflammatoryerosionofthinnedoverlyingmucosa Increasedtensioninprogressivelydilatedveins Increasedvascularhydrostaticpressureassociatedwith vomitingarelikelytocontributetomedicalemergencythat istreatedbyanyofseveralmethods: 1. 2. 3. Endoscopicrubberbandligation Sclerotherapy Endoscopicballoontamponade

Complicationsoflivercirrhosis ESOPHAGEALVARICES: Halfofpatientsdiefromthefirstbleedingepisodeeitherasa directconsequenceofhemorrhageorfollowinghepaticcoma triggeredbyhypovolemicshock. Additional50%within1year. Eachepisodehasasimilarrateofmortality. Overhalfofdeathsamongindividualswithadvanced cirrhosisresultfromvaricealrupture.

ESOPHAGEALVARICES: Complicationsoflivercirrhosis

Complicationsoflivercirrhosis Splenomegaly:Long-standingcongestion maycausecongestivesplenomegaly (spleenweightmayreachupto1000gm) Themassivesplenomegalymayinduce hematologicabnormalitiesattributableto hypersplenism,suchasthrombocytopenia orpancytopenia

Complicationsoflivercirrhosis Ascitesistheaccumulationofexcessfluidin theperitonealcavity:85% Serous:lessthan3gm/dLofprotein

Complicationsoflivercirrhosis Spontaneousbacterialperitonitis

Complicationsoflivercirrhosis JAUNDICEANDCHOLESTASIS

Complicationsoflivercirrhosis JAUNDICEANDCHOLESTASIS: Jaundiceandicterus:ayellowishorgreenish pigmentationoftheskinandscleraoftheeyes respectivelyduetohighbilirubinlevels. Cholestasis,characterizedbysystemicretention ofnotonlybilirubinbutalsoothersolutes eliminatedinbile.

Bilirubinmetabolism andelimination

Complicationsoflivercirrhosis CauseofJaundice 1.Prehepaticcausesofjaundice:Bilirubinoverproduction duetohemolysisandhematomaresorption,leadtoelevated levelsofunconjugated(indirect)bilirubin. 2.Intrahepaticdisorders canleadtounconjugatedorconjugatedhyperbilirubinemia.The conjugated(direct)bilirubinlevelisoftenelevatedbyalcohol, infectioushepatitis,drugreactions,andautoimmunedisorders. 3.Posthepaticdisorders(Obstructionoftheflowofbile) alsocancauseconjugatedhyperbilirubinemia.Gallstone formationisthemostcommonposthepaticprocessthatcauses jaundice;however,thedifferentialdiagnosisalsoincludes seriousconditionssuchasbiliarytractinfection,pancreatitis, andmalignancies

Complicationsoflivercirrhosis Coagulopathy

Coagulopathy Theliveristhesourceofanumberofcoagulationfactorsthat declineinthefaceofliverfailure,leadingtoeasybruising andbleeding

Complicationsoflivercirrhosis Hepaticencephalopathy

Complicationsoflivercirrhosis Hepaticencephalopathy spectrumofdisturbancesinconsciousnessrangingfrom subtlebehavioralabnormalities,toconfusionandstupor,to comaanddeath. maydevelopoverdays,weeks,orafewmonths Duetoelevatedammonialevelsinbloodandthecentral nervoussystemandbrainedema.

Complicationsoflivercirrhosis Hepatorenalsyndrome:

Complicationsoflivercirrhosis Hepatorenalsyndrome: Appearanceofrenalfailureinindividualswith severechronicliverdisease---nointrinsic morphologicorfunctionalcausesfortherenal failure. Theincidenceofthissyndromeisabout8%per yearamongpatientswhohavecirrhosisand ascites

Complicationsoflivercirrhosis Hepatorenalsyndrome: Decreasedrenalperfusionpressuredueto systemicvasodilation Activationoftherenalsympatheticnervous systemwithvasoconstrictionoftheafferent renalarterioles Increasedsynthesisofrenalvasoactive mediators,thatdecreaseglomerularfiltration.