Cirrhosis and Portal Hypertension Gastroenterology Teaching Project American Gastroenterological Association CIRRHOSIS AND PORTAL HYPERTENSION
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Cirrhosis and
Portal Hypertension
Gastroenterology Teaching Project American Gastroenterological Association
CIRRHOSIS AND PORTAL HYPERTENSION
What is Cirrhosis?
WHAT IS CIRRHOSIS?
Cirrhosis
• End stage of any chronic liver disease
• Characterized histologically by regenerative nodules surrounded by fibrous tissue
• Clinically there are two types of cirrhosis:• Compensated• Decompensated
DEFINITION OF CIRRHOSIS
CirrhosisNormal
Nodules
Irregular surface
GROSS IMAGE OF A NORMAL AND A CIRRHOTIC LIVER
CirrhosisNormal
Nodules surrounded by fibrous tissue
HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVER
What is the Natural History of Cirrhosis?
WHAT IS THE NATURAL HISTORY OF CIRRHOSIS?
Compensatedcirrhosis
Decompensatedcirrhosis Death
Chronic liver
disease
Natural History of Chronic Liver Disease
Development of
complications:
• Variceal hemorrhage• Ascites• Encephalopathy• Jaundice
NATURAL HISTORY OF CHRONIC LIVER DISEASE
Development of Complications in Compensated Cirrhosis
AscitesJaundiceEncephalopathyGI hemorrhage
Probability of developing
event
0
20
60
80
100
0 60
40
20 40 80 100 120 140 160
MonthsGines et. al., Hepatology 1987; 7:122
NATURAL HISTORY OF CIRRHOSIS
6040 80 100 120 140 1600
40
60
80
20
200
100
Months
Probability of survival
All patients with cirrhosis
Decompensated cirrhosis
180
Decompensation Shortens Survival
Gines et. al., Hepatology 1987;7:122
Median survival~ 9 years
Median survival~ 1.6 years
SURVIVAL TIMES IN CIRRHOSIS
Liver insufficiency
Variceal hemorrhage
Complications of Cirrhosis Result from Portal Hypertension or Liver Insufficiency
CirrhosisAscites
Encephalopathy
Jaundice
Portal hypertension
Spontaneous bacterial peritonitis
Hepatorenal syndrome
COMPLICATIONS OF CIRRHOSIS
Most complications of cirrhosis result from portal hypertension.
What mechanisms lead to portal hypertension?
MECHANISMS OF PORTAL HYPERTENSION
Cirrhosis - Diagnosis
• Cirrhosis is a histological diagnosis
• However, in patients with chronic liver disease the presence of various clinical features suggests cirrhosis
• The presence of these clinical features can be followed by non-invasive testing, prior to liver biopsy
DIAGNOSIS OF CIRRHOSIS
In Whom Should We Suspect Cirrhosis?
• Any patient with chronic liver disease• Chronic abnormal aminotransferases and/or
alkaline phosphatase
• Physical exam findings• Stigmata of chronic liver disease (muscle
wasting, vascular spiders, palmar erythema)• Palpable left lobe of the liver• Small liver span• Splenomegaly• Signs of decompensation (jaundice, ascites,
asterixis)
DIAGNOSIS OF CIRRHOSIS – CLINICAL FINDINGS
Laboratory• Liver insufficiency
• Low albumin (< 3.8 g/dL)• Prolonged prothrombin time (INR > 1.3)• High bilirubin (> 1.5 mg/dL)
• Portal hypertension• Low platelet count (< 175 x1000/µl)
• AST / ALT ratio > 1
In Whom Should We Suspect Cirrhosis?
DIAGNOSIS OF CIRRHOSIS – LABORATORY STUDIES
Increased intrahepatic resistanceis the initial mechanism leading to
portal hypertension
In Cirrhosis:
MECHANISMS OF PORTAL HYPERTENSION IN CIRRHOSIS
Imaging studies• Liver-spleen scan
• Small liver, irregular uptake• Splenomegaly• Colloid shift to bone marrow
• CAT scan / Ultrasound• Nodular liver• Splenomegaly• Venous collaterals
In Whom Should We Suspect Cirrhosis?
DIAGNOSIS OF CIRRHOSIS – IMAGING STUDIES
Small liver,irregular uptake
Splenomegaly
Colloid shift to bone marrow and ribs
Normal Cirrhosis
Liver-Spleen ScanDIAGNOSIS OF CIRRHOSIS – LIVER-SPLEEN SCAN
CAT Scan in Cirrhosis
Liver with an irregular surface SplenomegalyCollaterals
DIAGNOSIS OF CIRRHOSIS – CAT SCAN
Confirmatory Liver Biopsy Is Not Always Necessary in Cirrhosis
• Liver biopsy is not necessary in the presence of any of the following:− Decompensated cirrhosis (variceal
hemorrhage, ascites, encephalopathy)
− Liver-spleen and/or CAT scan diagnostic of cirrhosis
• Liver biopsy is not necessary for pre-transplant evaluation
DIAGNOSIS OF CIRRHOSIS
Normal Vascular Anatomy
Hepatic vein
Sinusoid
Portal vein
Hepatic artery
Liver
Splenic vein
Coronary vein
Inferiorvena cava
Inferior mesenteric vein
Superiormesenteric
vein
NORMAL VASCULAR ANATOMY OF THE LIVER
Normal Liver
Hepatic vein
Sinusoid
Portal vein
Liver
Splenic vein
Coronary vein
THE NORMAL LIVER OFFERS ALMOST NO RESISTANCE TO FLOW
Portal systemic collaterals
Distorted sinusoidal
architectureleads to
increased resistance
Portal vein
Cirrhotic Liver
Splenomegaly
ARCHITECTURAL LIVER DISRUPTION IS THE MAIN MECHANISM THAT LEADS TO AN INCREASED INTRAHEPATIC RESISTANCE
• Cirrhosis is the most common cause of portal hypertension
• The site of increased resistance in cirrhosis is sinusoidal
• Other causes of portal hypertension are classified according to the site of increased resistance
Causes of Portal Hypertension
CAUSES OF PORTAL HYPERTENSION
Portal Hypertension Is Classified According to the Site of Increased
ResistanceType Example
Pre-hepatic Portal or splenic vein thrombosis
Pre-sinusoidal Schistosomiasis
Sinusoidal Cirrhosis
Post-sinusoidal Veno-occlusive disease
Post-hepatic Budd-Chiari syndrome
CLASSIFICATION OF PORTAL HYPERTENSION
PRE-HEPATIC PORTAL HYPERTENSION
Pre-Hepatic Portal Hypertension
Hepatic vein
Sinusoid
Portal vein
Liver
Thrombus
Portosystemic collaterals
Splenomegaly
SINUSOIDAL PORTAL HYPERTENSION
Cirrhotic liver
Portal vein
Sinusoidal Portal HypertensionPortal systemic collaterals
Splenomegaly
POST-SINUSOIDAL PORTAL HYPERTENSION
Post-Sinusoidal Portal Hypertension
Sinusoid
Portal vein
LiverCentri-lobular
fibrosis
Portosystemiccollaterals
Splenomegaly
POST-HEPATIC PORTAL HYPERTENSION
Post-hepatic Portal Hypertension
Thrombus
Portal vein
LiverSinusoid
Splenic vein
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