Dr. Ezra De León Arias
Gastroenterology, Liver, Motility, and Endoscopy
MULTIMEDICA VISTA HERMOSA
Diffuse and irreversible alteration of the liver’s structure caused by fibrosis and the regeneration nodes, which reduces the functional hepatic mass and alters the intrahepatic vascularization. Its consequences are hepatic failure and portal hypertension with its complications.
Clinical and analytical data are the basis to suspect cirrhosis but its diagnostic is purely histological. In our community it is mainly caused by alcohol and hepatitis virus b and c, but there are other less common etiology such as autoimmune (specifically type I), chronic biliary disease (CBP mainly), metabolic diseases (hemochromatosis, Wilson’s disease, alfa-1-antitrypsin deficiency, porphyries), toxic drug related, chronic vein obstruction, and cryptogenic diseases.
The most common causes why cirrhotic patients go to the emergency room are due to an imbalance caused by:
- Hepatocellular insufficiency worsens: jaundice, hemorrhagic diathesis, and encephalopathy.
- Portal hypertension complications: upper gastrointestinal bleeding, ascites, and encephalopathy.
- Infections: spontaneous bacterial peritonitis (SBP), urinary tract or respiratory infections.
- INSPECTION: the nutritional state needs to be evaluated (muscle atrophy) as well as pale skin (anemia due to multiple factors), jaundice, bruising and/or epistaxis, telangiectasias and/or vascular spiders (in the upper vena cava), parotid hypertrophy, Dupuytren’s palm contractions, ungual opacity, loss of lunula, gynecomastia, collateral circulation in the abdominal wall, umbilical hernia.
- CARDIO-RESPIRATORY AUSCULTATION.
- ABDOMINAL EXPLORATION: hepatosplenomegaly, flank dullness, abdominal distension, ascetic wave, hernias.
- DETECTING COMPLICATIONS: edemas, testicular atrophy, melenic stool, asterixis (if encephalopathic).
- Frequent checkups (Tª, FC, TA, O2 saturation %)
Physical exploration for a cirrhotic patient should include:
If the patient has a fever, depending on the clinic, PBE must be ruled out (E.Coli and gram positive cocci, fundamentally), urinary tract infection (gram-negative bacilli), pneumonia (pneumococcal enolic and anaerobic if aspirated), tuberculosis, complicated hepatocarcinoma, and acute alcoholic hepatitis.
Complimentary explorations that must take place in the emergency room include:
Blood analysis: hemogram, coagulation, biochemical profile (with hepatic and renal function tests), and electrolytes. Determine if there is ammonium (if encephalopathy is suspected). Urine analysis: sediments, cultures (if an infection is suspected) and electrolytes. Paracenthesis diagnostics: erythrocytes, leukocytes, (neutrophiles), complete protein check, albumin, Gram, culture and cytology. Blood gas: if dyspnea or respiratory infection. Chest X-ray: revue if the lung volume has decreased, vascular redistribution, pleural effusion (toracoascithis), pneumonia. Abdomen X-ray: evaluate if there was a decrease on the transverse colon due to hepatomeagalia, a “frosted glass” pattern (ascites), stool in the colon structure (encephalopathy).
Ultrasound this can provide information on:
- Liver: size, morphology, hepatocarcinoma.
- Spleen: size.
- Splenoportal axis (doppler): diameter, hepatopetal flow/hepatofugal thrombosis.
- Collateral circulation: varicose veins, patency of the umbilical vain restored.
As you can see there are several manifestations and findings on a cirrhotic patient, it is a complex disease to detect and handle. It is very important that if suspected, the disease be detected since depending on the results, it can be handled and stabilized to reduce the chances of mortality.