2 min read - Cirrhosis

A 55 years old male patient admitted to medical casualty with a febrile illness for 3 days with myalgia. Examination was unremarkable. He was previously well except for chronic bilateral knee joint osteoarthritis. He consumed liquor quarter to half a bottle on a daily basis.

Investigations revealed.

WBC - 5.6
Hb - 11.2
Plt - 135

AST - 45
ALT - 42

S.Cr - 54

He was managed as viral fever and became fever free the next day. However the platelet count was persistently low around 130.

Further investigations arranged.

Blood picture - Thrombocytopenia probably due to liver disease
S. Bilirubin, ALP - Normal
S. Albumin - 38, S globulin - 37
USS abdomen - Coarse echogenicity of liver. Mild portal hypertension. Mild splenomegaly. Compatible with chronic liver cell disease.

This patient has Cirrhosis with portal hypertension.


Now the obvious cause for his cirrhosis is alcohol, isn't it?

NO! Just because of the history of significant alcohol consumption you cannot attribute cirrhosis to alcohol. How many people have you seen drinking bottles of liquor a day and have no cirrhosis?


Then?

Cirrhosis is a nasty disease. When it's advanced the prognosis is poor without liver transplantation. Survival in a patient with decompensated cirrhosis with a Child score (See below) of 12 or more is less than 6 months!

Therefore it's paramount to look for aetiologies that can be treated!


For what causes are you going to evaluate this patient?

This patient, as well as any other patient with newly diagnosed cirrhosis should be evaluated at least for

1. Hemochromatosis
2. Chronic hepatitis B and C
3. Wilsons disease
4. Autoimmune hepatitis

Of course there are other causes as well. You can do further investigations if the history or examination is suggestive.

Always take a history and examine to look for

1. Hemochromatosis (Arthritis, Endocrinopathies including diabetes, Pigmentation, Family history)
2. Chronic hepatitis B and C (Drug abuse, Blood transfusions, High risk sexual behaviour)
3. Wilsons disease (Patients history of family history of movement disorders, psychiatric illnesses)
4. Autoimmune hepatitis (Other autoimmune features)


What investigations would you consider?

Serum Ferritin and transferrin saturation.
Hepatitis B surface antigen, Hepatitis C antibody.
Serum Ceruloplasmin level, Eye assessment to look for KF rings.
ANA


Are these diseases common? Have you seen even one?

Well, just visit a gastroenterology/hepatology clinic at any major hospital. You will be surprised!


Let's discuss about management of those diseases later. Imagine this patients investigation did not lead to any diagnosis. What are you going to do now.

If I summarize

1. Assess liver disease severity

Look for jaundice, ascites, encephalopathy, edema. Follow up with PT/INT and full liver profile to stage the disease.
Child Pugh score is the most widely used score for staging the disease and determine prognosis.

2. Look for other complications

Arrange an upper GI endoscopy to look for varices. If present start the patient on a beta blocker.
At least annual ultrasound scans to look for development of hepatocellular carcinoma.


3. Try to prevent progression of the disease

Stop alcohol.
Treat underlying disease if identified.
Avoid hepatotoxic drugs.


4. General management

Low salt diet.
Optimize nutrition.
Keep 2-3 bowel motions a day. (May not be applicable to this patient)


Any take home message?

CIRRHOSIS IN A PATIENT WHO CONSUMES ALCOHOL IS NOT ALWAYS DUE TO ALCOHOL !!