1. CIRRHOSIS OF LIVERCIRRHOSIS OF LIVER
Dr. Mizanur Rahman Chowdhury

2. EpidemiologyEpidemiology
40% cases asymptomatic
It is the 12th
leading cause of death in
United States.
Approximately 30,000 to 50,000 deaths
per year
Additional 10,000 deaths due to liver
cancer secondary to cirrhosis

3. CirrhosisCirrhosis
Definition: It is the end stage of liver
disease characterized by
Bridging fibrous septa in the form of
delicate bands or broad scar linking
portal tracts with one another and portal
tracts with terminal hepatic vein
Parenchymal nodules containing
hepatocytes encircled by fibrosis
Disruption of architecture entire of liver

4. Normal LiverNormal Liver

5. Normal Liver HistologyNormal Liver Histology
CV
PT

6. Histological classificationHistological classification
Micronodular Cirrhosis :Thick
regular septa and regenerating small
nodules varying little in size and
involvement of every lobule, mainly
seen in alcoholic cirrhosis.
Size of the nodule is less than 1cm

7. Histological classificationHistological classification
Micronodular Cirrhosis

8. Micronodular cirrhosis:Micronodular cirrhosis:

9. Histological classificationHistological classification
Macronodular Cirrhosis :Septa
and nodules of variable size and
normal lobules in larger nodules,
mainly seen in post necrotic
cirrhosis.
Size of the nodule is more than 1cm

10. Histological classificationHistological classification
Macronodular Cirrhosis

11. Histological classificationHistological classification
Macronodular Cirrhosis

12. Aetiological classificationAetiological classification
Viral: Chronic Hepatitis B, Hepatitis C
infection.
Alcohol
Non alcoholic fatty liver
Metabolic disorder:
Haemochromatosis, Wilson’s
disease,Alpha-1 antripsin deficiency.
Autoimmune Hepatitis
Primary biliary cirrhosis

13. Aetiological classificationAetiological classification
Prolong cholestasis
Hepatic venous outflow obstruction:
Constrictive pericarditis, Veno occlusive
disease, Budd chairi syndrome.
Drugs: Methotraxate, Amioderone.
Cryptogenic: Unknown origin.

14. Etiology of CirrhosisEtiology of Cirrhosis
Alcoholic liver disease 60-70%
Viral hepatitis 10%
Biliary disease 5-10%
Primary hemochromatosis 5%
Cryptogenic cirrhosis 10-15%
Wilson’s, α1AT def rare

15. Pathogenesis of cirrhosisPathogenesis of cirrhosis
Hepatocellular death
Regeneration
Progressive fibrosis
Normal liver consists of I, III , IV Collagen
in portal tracts and around central veins.
A delicate reticulin network of IV collagen
in the space of disse “( b/w sinusoidal
endothelial cell and hepatocyte.) In
cirrhosis there is deposition of type I, III
and other components of ECM are
deposited in all portion of lobule .

17. Pathogenesis of cirrhosisPathogenesis of cirrhosis
The induction of fibrosis occurs with
activation of hepatic stellate cells,
resulting in formation of increased
amounts of collagen & other
components of extracellular matrix.
Stimuli :
o1.Chr.inflammation – cytokines like TNF,
Lymphotoxin, IL-1
o 2.Cytokine production by injured
Kupffer cells, endothelial cells,
hepatocytes, bile duct epithelial cells

18. Pathogenesis of cirrhosisPathogenesis of cirrhosis
o 3.Disruption of ECM
o 4.Direct stimulation of stellate cells by
toxins
On the other hand portal hypertension
developed in following way

19. Pathogenesis of cirrhosisPathogenesis of cirrhosis
Necrosis of hepatic parenchyma due to some injury
Collapse of hepatic lobule
Formation of diffuse fibrous septa
Nodular regrowth of liver cells
Altered hepatic vasculature
Portal blood flow is impaired
Development of portal hypertension
Cirrhosis of liver

20. CirrhosisCirrhosis
Fibrosis
Regenerating Nodule

21. Liver Biopsy – CirrhosisLiver Biopsy – Cirrhosis

22. Liver Biopsy – Cirrhosis:Liver Biopsy – Cirrhosis:

23. Alcoholic cirrhosisAlcoholic cirrhosis
Ethyal alcohol is a common cause of
acute/chronic liver disease.
Paterns of alcoholic liver disease:
1. Fatty change
2. Acute Hepatitis
3. Chronic hepatitis with fibrosis
4. Cirrhosis, Chronic liver failure
All are reversible except cirrhosis
stage

24. Pathogenesis of Alcoholic cirrhosisPathogenesis of Alcoholic cirrhosis
Acetaldehyde – metabolite – hepatotoxic
Diversion of metabolism – fat storage
Oxidation of ethanol NAD to NADH. NAD is
required for the oxidation of fat..
Increased peripheral release of fatty acids
Inflammation, Portal bridging fibrosis
Stimulates collagen synthesis – fibrosis
Micronodular cirrhosis

25. Alcoholic Liver DamageAlcoholic Liver Damage

26. Alcoholic Fatty LiverAlcoholic Fatty Liver

27. Alcoholic Fatty LiverAlcoholic Fatty Liver

28. Alcoholic Fatty LiverAlcoholic Fatty Liver

29. Clinical Feature of cirrhosisClinical Feature of cirrhosis
Symptoms:
 Non specific symptoms:
weakness, fatigue, anorexia
 Jaundice
Abdominal distension
Swelling if legs
Loss of libido in males and amenorrhoea
in females.
Low grade fever
Less commonly symptoms of complication
such as epistaxis, heamatemesis,
melaena, menorrhagia.

30. Clinical Feature of cirrhosisClinical Feature of cirrhosis

31. Clinical Feature of cirrhosisClinical Feature of cirrhosis
Signs:
 Jaundice
 Fetor hepaticus
 Pedal oedema
 Generalized wasting
 Hands: Leuconychia, clubbing, Jaundice,
Flapping tremor, palmar erythema, dupuytren’s
contructure

32. Clinical Feature of cirrhosisClinical Feature of cirrhosis
Parotid enlargement in alcoholic
cirrhosis
Loss of secondary sexual hair, axillary
and pubic
Gynaecomastia in males and breast
atrophy in females.
Testicular atrophy in males.
skin: spider naevi in the upper limbs
and chest, generalized pigmentation,
purpura, bruising

33. Clinical Feature of cirrhosisClinical Feature of cirrhosis
Abdomen :
Dilated abdominal vessels, caput medusa
 Ascitis
Splenomegaly
Hepatomegaly
Haemorrhoid

34. Palmar erythemaPalmar erythema

35. Clinical Feature of cirrhosisClinical Feature of cirrhosis

36. Ascitis in CirrhosisAscitis in Cirrhosis

37. Porta-systemic anastomosis:Porta-systemic anastomosis:
Prominent abdominal veins.Prominent abdominal veins.

38. Gynaecomastia in cirrhosisGynaecomastia in cirrhosis

39. Splenomegaly in cirrhosisSplenomegaly in cirrhosis

40. Submucosal veins in the esophagus become dilated. TheseSubmucosal veins in the esophagus become dilated. These
are known as esophageal varices. Varices are seen here inare known as esophageal varices. Varices are seen here in
the lower esophagus as linear blue dilated veins. There isthe lower esophagus as linear blue dilated veins. There is
hemorrhage around one of them. Such varices are easilyhemorrhage around one of them. Such varices are easily
eroded, leading to massive gastrointestinal hemorrhageeroded, leading to massive gastrointestinal hemorrhage

41. Lab investigationsLab investigations
Liver function: serum albumin and
prothrombin are the best indicator of liver
functions.
o Albumin is less than 28 g/l
oProthrombin time increase according to the
severity of the disease
oSerum bilirubin is elevated
Liver biochemistry: this can be normal
depending on the severity of the cirrhosis
oALP is elevated
oALT is elevated

42. Lab investigationsLab investigations
Serum electrolytes: A low sodium indicate
severe disease due to defect in the free
water clearance or excess diuretic
therapy.
 Serum Creatinine: An elevation
concentration of more than 130micromol/l
indicate worse prognosis
In addition Alpha feto protein more than
200ng/ml strongly suggest that hepato
cellular carcinoma

43. Lab investigationsLab investigations
 Other test to identify the cause
Viral marker : HBsAg,Anti HCV
Alpha-1 antitripsin
Serum copper, Caeruloplasmin
Serum immunoglobulin
Auto antibody
Iron indices,ferritin

44. ImagingImaging
Ultrasonogram examinition:
◦ Liver may show coarse ecotexture
◦ Dilated portal veins
◦ Splenomegaly
◦ Ascitis
CT scan may show hepatosplenomegaly
and dilated collaterals are seen in chronic
liver disease
Upper GI endoscopy: Oesophageal varices
may seen
 LIVER BIOPSY IS CONFIRMATORY

45. Prognosis of CirrhosisPrognosis of Cirrhosis
Poor prognostic indicator of cirrhosis:
Blood tests
 low Serum albumin is( <28 g/l)
Low Sodium is (<125mmol/l)
Prolong prothrombin time(> 6sec)
Serum Creatinine is (> 130micromol/l)
Clinical
Persistent jaundice
Ascitis
Failure of response to therapy
Hemorrhage from the varices,particolarly with
poor liver function

46. Prognosis of CirrhosisPrognosis of Cirrhosis
Neuropsychiatric complications developing
with progressive liver failure
Persistent hypertension
Small liver
Aetiology eg.alcoholic cirrhosis if the
patient continue to drink alcohol

47. Prognosis of CirrhosisPrognosis of Cirrhosis
Prognosis can be assessed by using
CHILD-PUGH CLASSIFICATION
Prameter
Ascitis None Mild Moderate/
Severe
Enchaphalopath
y
None Mild Marked
Bilirubin <2mg/dl 2-3mg/dl >3mg/dl
Albumin >3.5g/dl 2.8-3.5g/dl <2.8g/dl
Prothrombin
time
<4 4-6 >6

48. Prognosis of CirrhosisPrognosis of Cirrhosis
Score5-6 grade A (well-compensated
disease)
Score 7-9 grade B (Significant functional
compromise)
Score 10-15 grade C (Decompensated
disease)

49. Complication of cirrhosisComplication of cirrhosis
1. Ascitis
2. Spontaneous bacterial
peritonitis
3. Heamatemesis
4. Enchaphalopathy
5. Hepatocellular carcinoma
6. Hepato renal syndrome
7. Increased susceptibility of
infection

50. THANKYOU