Cirrhosis and hepatoma

For C1 students
What is cirrhosis?
 Introduction
• Hepatic fibrosis
– Fibrosis is a wound healing response in which
damaged regions are encapsulated by an
extracellular matrix or scar

– Chronic liver injury at variable rates

– Requires several months to years of ongoing injury
– Fibrosis is reversible in its initial stages
– Progressive fibrosis can lead to cirrhosis
 Introduction
• Cirrhosis
– Is defined histopathologically
– Has a variety of clinical manifestations and
complications
– In the past, it has been thought that cirrhosis
was never reversible
– When the underlying insult has been removed,
there can be reversal of fibrosis
• Pathologic features :
– The development of fibrosis to the point that
there is architectural distortion with the formation
of regenerative nodules

o Decrease in hepatocellular mass and function

o Alteration of blood flow
List causes of cirrhosis
• Structural changes in the liver may cause impairment
of hepatic function manifested as
Jaundice
 Portal hypertension and varices
 Ascites
Hepatorenal syndrome
Spontaneous bacterial peritonitis
Hepatic encephalopathy
Progressive hepatic failure
 CLASSIFICATION
 Morphologic classification
• Micronodular cirrhosis 3mm
• Macronodular cirrhosis 3mm
• Mixed cirrhosis

 Etiologic classification
• preferred
 Pathologic criteria for diagnosis of cirrhosis
 Nodularity (regenerating nodules)
 Fibrosis (deposition of connective tissue creates
pseudolobules)
 Fragmentation of the sample
 Abnormal hepatic architecture
 Hepatocellular abnormalities
 Pleomorphism
 Dysplasia
 Regenerative hyperplasia
• Information obtained from histologic examination
– Establishment of the presence of cirrhosis
– Determination of the cause of cirrhosis in some cases
– Assessment of grade of histologic activity
• Specific histologic methods for determining the
cause of cirrhosis
– Immunohistochemistry (e.g., hepatitis B virus)
– Polymerase chain reaction (PCR) techniques (e.g.,
hepatitis C virus)
 CLINICAL FEATURES
• Patients with cirrhosis may come to clinical attention in numerous ways

o Stigmata of chronic liver disease (e.g., palmar erythema, spider

telangiectasias

o Abnormal serum chemistry test results and hematologic indices

o Radiographic abnormalities

o Complications of decompensated liver disease (e.g., ascites, variceal

hemorrhage)

o Cirrhotic appearance of the liver at the time of laparotomy or laparoscopy

o Autopsy
What are complication of cirrhosis?
 COMPLICATIONS
• Ascites
• Spontaneous bacterial peritonitis
• Variceal hemorrhage
• Hepatic encephalopathy
• Hepatocellular carcinoma
• Hepatorenal syndrome
Diagnosis
• Laboratory evaluation
 Tests of hepatocellular injury
 Aminotransferases (aspartate aminotransferase [AST]
and alanine aminotransferase[ALT])

 Tests of cholestasis
 Alkaline phosphatase
 Serum bilirubin (conjugated and unconjugated)
 Gamma glutamyltranspeptidase (GGTP)
 5′-Nucleotidase
 Tests of synthetic function
– Serum albumin
– Prothrombin time

 Special tests to aid in diagnosis

– Viral hepatitis serology
– PCR
– Iron study, genetic testing for the HFE
gene mutation (hemochromatosis)
– Ceruloplasmin, serum and urinary copper (Wilson disease)
– Alpha-1 antitrypsin level and protease inhibitor type
– Serum immunoglobulins (autoimmune hepatitis)
– Autoantibodies: antinuclear antibodies (ANA), antimitochondrial antibodies
(AMA),
anti–liver kidney microsomal antibodies (LKM), anti–smooth muscle
antibodies
(SMA) (autoimmune hepatitis, primary biliary cirrhosis)
 Screening test for hepatocellular carcinoma
carcinoma:: serum alpha fetoprotein
 Imaging studies
– Abdominal ultrasonography
– CT
– MRI
– Radionuclide studies
 Liver biopsy
 The gold standard for the diagnosis of cirrhosis
Prognosis
 Prognosis
• Model for End Stage Liver Disease (MELD)
– Bilirubin levels, creatinine, INR, and the etiology of
cirrhosis
– Estimate relative disease severity and likely
survival of patients awaiting liver transplantation
 Treatment principles
• Treatment of underlying diseases
• Management of complications
• Surveillence for hepatocellular carcinoma
• Vaccination of cirrhotic patients against hepatitis
A and B
• Advised to avoid alcohol and other hepatotoxins
• Transplantation
 HEPATOCELLULAR CARCINOMA
• HCC is one of the most common malignant diseases
worldwide
 Clinical features
• The most frequent symptoms
– Abdominal pain or discomfort and weight loss
• Occasionally rupture
• manifesting as an acute abdomen

• Many patients are asymptomatic

• With the tumor detected incidentally or during
screening of at-risk person

• Paraneoplastic manifestations
• Hypoglycemia
• Erythrocytosis
• Hypercholesterolemia and feminization
• Hypercalcemia
 Diagnosis
• Biopsy
– Research gold standard
– Inter-observer error
• Imaging
– Clinical gold standard
• Limitations at small size
– Contrast at different times
• Hypervascular on arterial phase
• Washout on delayed phase
• Limitation of Alpha
Alpha--Fetoprotein

False positive of high AFP

• Severe hepatitis (acute, ;flare)
• Pregnancy/Gonadal tumours
• Gastric/Colon cancers
• Intrahepatic Cholangiocarcinoma*

False negative of high AFP

• AFP rarely elevated in curable HCC
Treatment
Thank you