RISK FACTORS OR CAUSES :
• Alcoholism and hepatitis C cause 60%
• Hepatitis B
• Progressive fatty liver
• Nonalcoholic steatohepatitis
. Biliary cirrhosis
. Hemachromatosis
. Less frequent causes
. Wilson disease, alpha-1-antitrypsin defi ciency
. Hepatotoxic drugs
. Chronic and recurrent heart failure
. Chronic biliary obstruction
. Sclerosing cholangitis
. Cystic fibrosis
. Polycystic or multiple telangiectasis diseases
. Veno-occlusive disease
. Granulomatous liver disease
. Idiopathic portal fi brosis
. Shared intravenous needles
. Multiple transfusions before 1994
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D.D. -
* ALCOHOLIC CIRRHOSIS
* INDIAN CHILDHOOD CIRRHOSIS
* INFECTIONS LIKE HEPATITIS B- DISEASE, HEPATITIS C- DISEASE, SYPHILIS, SCHISTOSOMIASIS
* CHR ACTIVE HEPATITIS - LUPOID HEPATITIS ( AUTOIMMUNE CHR ACTIVE HEPATITIS )
- DRUGS LIKE ANTICONVULSANTS, OXYPHENACETIN, METHYLDOPA & ANTITUBERCULAR DRUGS
* GENETIC DEFECTS - HAEMACHROMATOSIS, WILSONS DISEASE, GALACTOSAEMIA, GLYCOGEN STORAGE DISEASES, ALPHA-1 ANTITRYPSIN DEFICIENCY
* BILIARY DISEASES - LONG STANDING EXTRAHEPATIC BILIARY OBSTRUCTION, PRIMARY BILIARY CIRRHOSIS, SCLEROSING CHOLANGITIS, CONGENITAL HEPATIC FIBROSIS
* VENOUS CONGESTION - CARDIAC FAILURE, CONSTRICTIVE PERICARDITIS, BUDD-CHIARI SYNDROME
* JEJUNO-ILEAL BYPASS
* Changes of hepatic cell injury :
. ALT, AST most commonly elevated
. Globulin increased if chronic
. Protein electrophoresis shows broad band elevation
* Changes of cholestasis :
. Alkaline phosphatase elevated
. GGTP elevated
. 5f-nucleotidase, is liver specifi c alkaline phosphatase
. Bile acids elevated
. Cholesterol elevated (when condition chronic)
* Changes of impaired amount of functioning liver :
. Reduced albumin
. Prolonged INR for prothrombin time
. Elevated bilirubin
* Changes suggesting portal hypertension and large spleen :
. Diminished platelet count
* Specific tests to determine etiology :
. Hepatitis
- Hepatitis B surface antigen, hepatitis B DNA viral load
- Anti-hepatitis C antibody, hepatitis C RNA viral load
. Alcoholism - alcohol in serum in patient who claims to be abstinent
- Carbohydrate deficient transferrin
- Elevated GGTP (gamma glutamyl transpeptidase) with normal alkaline phosphatase and decreased K, Mg, Zn or phosphate
. Biliary cirrhosis - antimitochondrial antibody
. Chronic active hepatitis - anti-smooth muscle, or antinuclear antibody
. Hemachromatosis - iron saturation >50%, increased ferritin, gene
. Hepatolenticular degeneration (Wilson disease) ceruloplasmin, copper excretion
. Hepatocellular carcinoma - alpha fetoprotein
SPECIAL TESTS:
• Endoscopy: identifies esophageal varices or portal hypertensive gastropathy, other bleeding lesions, and to effect emergency treatment of the bleeding lesion if necessary
• Electroencephalography may be required to clarify etiology of confusion
• Diagnostic paracentesis to clarify etiology of ascites and possible complications
• Liver biopsy is the gold standard of diagnosis. Can be conducted safely in a percutaneous fashion if INR < 1. 5 and there is no bleeding tendency and modest or no ascites. Otherwise transjugular biopsy must be performed by an experienced radiologist, infrequently available.
IMAGING :
• Ultrasound sometimes required to verify ascites
• Doppler ultrasound used to indicate patency of hepatic and portal veins
• Ultrasound to identify status of biliary passages and presence of gall bladder stones, shows scars in liver. Usually done just before liver biopsy to determine
optimal needle insertion site.
• If status of the extrahepatic biliary passages uncertain, CT scan or magnetic resonance exam. If stones likely or biopsy required ERCP is then performed.
• Abdomen CT scan may clarify scars of cirrhosis vs. metastatic disease or fatty liver
• MRI performed to clarify patency of blood vessels and collaterals as in Budd-Chiari syndrome, thrombosis of portal vein, varices or periumbilical collaterals. It also clearly identifi es the extrahepatic biliary passages.
• Endoscopic ultrasound useful to identify dilated common duct or masses in the pancreas. Guided needle biopsy can determine histology.
DIAGNOSTIC PROCEDURES:
• History, examination, biochemistry and imaging provide diagnosis more than half the time
• Liver biopsy performed 80% of time to verify probable diagnosis or establish uncertain one and to clarify prognosis
OTHER TESTS:
LUPOID HEPATITIS - SMOOTH MUSCLE ANTIBODIES & ANA TEST POSITIVE, HIGH LEVELS OF IGG.