Liver Diseases and Cirrhosis

Liver Injury & Jaundice Basics - Yellow Peril Primer

• Liver Injury Markers:
  • Hepatocellular: ↑ALT (📌 Alanine Transaminase - more Liver specific), ↑AST. De Ritis ratio ($AST/ALT$) >2 suggests alcoholic liver disease.
  • Cholestatic: ↑ALP, ↑GGT, ↑Conjugated Bilirubin.
• Jaundice: Yellow hue (sclera, skin) if serum bilirubin >2.5-3 mg/dL.
• Approach to Jaundice:

⭐ Gilbert's syndrome: Common, benign; mild unconjugated hyperbilirubinemia due to ↓ UDP-glucuronyltransferase activity, often provoked by fasting/illness.

Cirrhosis Path & Problems - Scarred Liver Saga

• Pathophysiology: Irreversible fibrosis, nodule formation. Stellate cell activation → collagen deposition.
• Etiologies (India Focus):
  • 📌 VWHAPPENS: Viral (HBV, HCV), Wilson's/ Hemochromatosis, Autoimmune hepatitis, PSC/PBC, NASH/NAFLD, Ethanol, Something else (e.g., drugs, Budd-Chiari).
• Severity Scoring:
  • Child-Pugh Score: Components (Bilirubin, Albumin, INR, Ascites, Encephalopathy - 📌 BEA AI). Score: 5-6 (Class A), 7-9 (Class B), 10-15 (Class C).
  • MELD Score: $3.78 \times \ln(\text{Bilirubin mg/dL}) + 11.2 \times \ln(\text{INR}) + 9.57 \times \ln(\text{Creatinine mg/dL}) + 6.43$. Predicts 3-month mortality.
• Key Problems: Portal hypertension (varices, ascites, SBP), hepatic encephalopathy, hepatorenal syndrome, HCC.

⭐ Most common causes of cirrhosis in India: Alcohol, Viral Hepatitis (HBV, HCV), and NAFLD (Non-Alcoholic Fatty Liver Disease).

Cirrhosis Complications Pt 1 - Pressure Cooker Effects

• Portal Hypertension (PHT): HVPG > 5 mmHg (clinically significant > 10 mmHg). Effects:
  • Varices: Esophageal (most common), gastric. Bleed risk: size, red signs, Child C.
    • Acute Bleed Management:

-   **Ascites**: Pathophys: PHT → splanchnic vasodilation → RAAS activation → Na+/water retention.
    +   Diagnosis: SAAG > **1.1 g/dL**.
    +   Management: Na+ restriction (<**2g/d**), Diuretics (Spironolactone ± Furosemide).
    ![Portosystemic anastomoses in portal hypertension](https://ylbwdadhbcjolwylidja.supabase.co/storage/v1/object/public/notes/L1/Internal_Medicine_Gastroenterology_Liver_Diseases_and_Cirrhosis/02a7a2cb-efd0-4edb-85fb-27b56cc43995.jpg)
-   **Spontaneous Bacterial Peritonitis (SBP)**: Infection of ascitic fluid.
    +   Diagnosis: Ascitic PMN > **250 cells/mm³** (+ culture).
    +   Treatment: IV Cefotaxime.
    > ⭐ SBP Prophylaxis (Norfloxacin): High-risk (prior SBP; or ascites protein < **1.5 g/dL** + severe liver/renal dysfunction).

Cirrhosis Complications Pt 2 & Management - Brain Fog & Beyond

• Hepatic Encephalopathy (HE): Neuropsychiatric; ↑ammonia.

  • Grades 0-4 (West-Haven).
  • 📌 Precipitating factors (HIDALGO): Hypokalemia, Infection, Dehydration, Azotemia, Lactulose non-compliance, GI bleed, Other sedatives.
  • Management:
    • Lactulose 30-45ml TID (target 2-3 soft stools/day).
    • Rifaximin 550mg BID (add-on/recurrent).
  • 
  • HE Management:

• Hepatorenal Syndrome (HRS): Functional renal failure.

  • Type 1: Rapid (sCr >2.5 mg/dL in <2wks).
  • Type 2: Slower, refractory ascites.
  • Management: Albumin + Vasoconstrictors (Terlipressin/Noradrenaline).

• Hepatopulmonary Syndrome (HPS): Intrapulmonary vascular dilatations + hypoxemia.

• Portopulmonary Hypertension (POPH): PAH with portal HTN.

⭐ HCC Screening: Ultrasound +/- AFP every 6 months in cirrhotic patients.

High‑Yield Points - ⚡ Biggest Takeaways

• Child-Pugh & MELD scores assess cirrhosis severity and prognosis.
• SBP diagnosis: ascitic fluid PMN > 250/mm³; treat with cefotaxime.
• Hepatic encephalopathy precipitated by infections/GI bleed; manage with lactulose/rifaximin.
• Interpret Hepatitis B serology (HBsAg, anti-HBs, anti-HBc) accurately.
• Screen for HCC in cirrhotics with ultrasound +/- AFP every 6 months.
• Manage acute variceal bleeding with vasoactive drugs and endoscopic therapy.
• Paracetamol and ATT drugs are common causes of DILI.