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!"#$%&"#$"'()*+$,-.-$ /'0)1*23'45 ! !"##$%&"& !"#$#%$&'#"&$('#)* +',$&!-#*!./)"!" &+$&# +$"#/'"0%&'1#!2#3!1'",/'$1#1!"&)/&!)2#)*#2)/4$%# +',$&!-#$/-+!&'-&0/'5 ! '()*+",-."/#%&"&-!"#)6'/%7#'80.'/$2)021# !"#$%$&$'% +'$%!2(#!2#3+!-+#'8-'""!6'#-)22'-&!6'#&!""0'# .0!%1"#0,#!2#&+'#%!6'/5#9+'#'8&/$-'%%0%$/#4$&/!8#!"# )6'/,/)10-'1:#1'(/$1'1#1'*!-!'2&%7:#)/#.)&+5# 9+'#&/!(('/#!"#-+/)2!-#!2;0/7:#'",'-!$%%7#!*#&+'/'#!"# $2#!2*%$44$&)/7#-)4,)2'2&5# Etiology • Hepatotoxicity • Long-standing alcohol abuse • Medications (e.g., acetaminophen, amiodarone or chemotherapy drugs such as methotrexate) • Ingesting aflatoxin created by Aspergillus. A toxin and carcinogen that is produced by Aspergillus flavus. Aspergillus flavus can grow on improperly stored food such as nuts, pistachios, rice, and corn. Acute ingestion can result in acute failure. Chronic ingestion increases the risk of (HCC). • Inflammation • Chronic viral B, C, and D • Primary sclerosing cholangitis • • Parasitic infections (e.g., schistosomiasis, leishmaniasis, malaria) (&$')'*+ ! 0"%$1&.()23(4&53"54 ! )%(*!#+%,%#'+-.$/!$%,/0!$'$'. 1)2345 ! 4/6%+,7%6!$%.'. !"#$%&'()'"#*+$+,"-./%!%$$01%'023%/0*"2!%'+4'"'&%4%!*'02'*3%'567'8%2%9' 5%:"*+,%8"-);'-01%/'!0//3+$0$;'(/+2<%&'$=02;'&0"(%*%$',%--0*#$;'"/*3/"-80";'"2&' !"/&0+,)+:"*3)9 ! 8'#.%(9.-:'./!./ >2'"#*+$+,"-'/%!%$$01%',%*"(+-0!'&0$+/&%/'+4'!+::%/'?&#%'*+' >@ABC'8%2%',#*"*0+2D'02'E30!3'(+*3'0,:"0/%&'(02&028'*+'0*$' */"2$:+/*%/':/+*%02'?!%/#-+:-"$,02D'"2&'(0-0"/)'%F!/%*0+2'02!/%"$%' 4/%%'$%/#,'!+::%/;'-%"&028'*+'"!!#,#-"*0+2'02'*3%'(+&)9'G%"&$'*+' !+::%/'&%:+$0*$'02'*3%'-01%/'?%"/-)'$*"8%$D'"2&'+*3%/'+/8"2$'?-"*%/' $*"8%$D;',+$*'0,:+/*"2*-)'02'*3%'(/"02'"2&'!+/2%"'?H")$%/. 6-%0$!3%/'/028$D9'A/%$%2*"*0+2'021+-1%$'3%:"*0*0$'?+/'%1%2'!0//3+$0$D;' &%,%2*0";'"2&':"/=02$+20$,9 Etiology • Metabolic disorders • Alpha-1 antitrypsin deficiency • Hepatic vein congestion or vascular anomalies • Budd-Chiari syndrome Partial or complete occlusion of hepatic veins caused by thrombosis • Cardiac (congestive hepatopathy) • Osler-Weber-Rendu syndrome Vascular dysplasia that leads to an increase of fibrous septa in the liver. • Cryptogenic cirrhosis • Cirrhosis of uncertain etiology despite adequate diagnostical efforts ,-&.'*"%"/$/

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! 6"*08#%; ,"-"0$%;'-+$$'+4'"::%*0*%;'E%083*'-+$$;'2"#$%" !"#$#%&"'(#)$(*' ! LPQ :"02 ! >$*%/0F0$ !+,-"&#$( ! R#:#)*/%2S$ !+2*/"!*#/% Clinical signs. Complains. Observation ü Skin • Generally dry and atrophic • Telangiectasia: most commonly spider angiomata • Palmar erythema (plantar erythema also possible) • Decreased body hair • • Pruritus

ü White nails with ground glass opacity (Terry's nails) fingernails or toenails appear white with a characteristic "ground glass" appearance without any lunula. The condition is thought to be due to a decrease in vascularity and an increase in connective tissue within the nail bed ü Clubbed nails ü Edema ü Gynecomastia ü Hypogonadism (testicular atrophy) ü Caputmedusae Clinical signs.

Ø (HRS) • renal vasoconstriction resulting in hypoperfusion of the kidneys. • Oliguria up to anuria with progressive kidney failure • Serum creatinine > 1.5 mg/dL • Protein excretion < 500 mg/d • Hyponatremia with relative sodium deficiency • Low sodium excretion in urine (< 10 mmol/L) Ø GI bleeding (esophageal varices) • Vomiting • Melaena Clinical signs.

Ø • Clinical manifestations • Disturbances of consciousness, ranging • from mild confusion to coma • Fatigue, lethargy, apathy • Memory loss • Impaired sleeping patterns • Irritability • Disoriented, socially aberrant behavior (for e.g., defecating/urinating in public, shouting at strangers, etc.) • Slurred speech • Muscle rigidity • Diagnostics • Elevated blood ammonia levels • Assessment of mental status Ø Fetor hepaticus (breath of the dead or hepatic foetor), portosystemic shunting allows thiols to pass directly into the lungs. Physical examination. Percussion. Palpation

• Edema • , tender, nodules • Splenomegaly • Ascites Originally published by Appleton & Lange. Copyright © 1998 by The McGraw-Hill Companies, Inc. Laboratory tests

• Signs of hepatocyte destruction • Macrocytic anemia due to vitamin • ↑ Liver enzymes (AST, ALT) deficiency (B12, folic acid) • ↑ Bilirubin • Microcytic anemia due to chronic • ↑ Gamma-glutamyl transpeptidase blood loss (GGT) • ↑ Alkaline phosphatase • Thrombocytopenia in hypersplenism • ↑ GLDH • ↑ Ammonia • Serum protein electrophoresis • Signs of impaired hepatic synthesis • ↓ Albumin band • ↑ Prothrombin time (↑ INR) • ↑ Gamma band • ↓ Total protein (↓ albumin) • Alpha-1, alpha-2, and beta globulin fractions are unchanged • ↓ Cholinesterase • .-"))*/*0"#*%(

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• Abdominal ultrasound should be performed first. Possible findings include: • Liver form and structure • Liver size: initially enlarged, atrophies and shrinks with progression • Loss of intrahepatic portal and liver veins • Complications of cirrhosis such as . • CT scan • Typical findings • Relative hypertrophy of lobe • Regenerative nodules • Irregular liver surface • Indirect findings: ascites, splenomegaly, portocaval collaterals • Diagnostic procedures.

ØBiopsy • is the gold standard for diagnosis • unnecessary in the light of clinical, laboratory, and ultrasound evidence. • Identify the etiology of the cirrhosis. ØHepatocellular carcinoma (HCC) screening: abdominal ultrasound for patients with cirrhosis every 6 months and periodic monitoring of alpha-fetoprotein (AFP) Biopsy

Size of the regenerative Occurrence nodules Micronodular 1–3 mm •Following a chronic active process such as with slow progression; e.g.: • Chronic hepatitis B or C •Fibrosis • •Replacement of normal liver tissue with Macronodular > 3 mm •Following diffuse parenchymal necrosis with collagenous regenera relapses or acute course; e.g.: tive nodules (histologi • Relapse or fulminant cal staging is based • on the size of the Intoxications (e.g., death regenerative nodules) cap poisoning)

Both 1–3 mm and > 3 mm •Possible in every type of liver-damaging disease Treatment

• General approach • Treatment of the primary condition • Avoidance of hepatotoxic substances (e.g., alcohol, medication) • Routine vaccinations (influenza, pneumococcal disease, hepatitis A/B, tetanus ) • Balanced diet with adequate calorie intake, no protein restriction • Supplemental B vitamins • Medication (for treatment of complications see respective section) • : A liver transplant is the only curative option in advanced liver disease. •