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Internal MedicineGastroenterologyCirrhosis and Portal Hypertension

Cirrhosis and Portal Hypertension

Must-Not-Miss / Red Flags

  • Variceal hemorrhage: hematemesis, melena, hemodynamic instability
  • Spontaneous bacterial peritonitis (SBP): fever, abdominal pain, ascites – diagnostic paracentesis with PMN >250 cells/μL
  • Hepatorenal syndrome: rapid renal deterioration in decompensated cirrhosis
Patient Explanation
“Your liver has developed scar tissue over time. This can affect how it works and cause fluid buildup. We’ll manage the complications and help protect your liver.”
Board Fact
“The Child‑Pugh score and MELD score are used to assess severity and predict mortality in cirrhosis; MELD determines transplant priority.”
ICD-10
K74.60

Definition & Core Concept

Cirrhosis is the end‑stage of chronic liver disease, characterized by diffuse fibrosis and nodular regeneration, leading to portal hypertension, synthetic dysfunction, and risk of hepatocellular carcinoma.

Epidemiology & Risk Factors

  • Leading cause of liver‑related death worldwide
  • Common causes: hepatitis C, alcohol‑related liver disease, non‑alcoholic fatty liver disease (NAFLD), hepatitis B
  • Compensated cirrhosis has median survival >12 years; decompensated (ascites, variceal bleed, encephalopathy) median survival ~2 years

Pathophysiology (Rule of 3)

  1. Chronic hepatocyte injury → inflammation and stellate cell activation → fibrosis
  2. Nodular regeneration distorts hepatic architecture → increased intrahepatic resistance → portal hypertension
  3. Portal hypertension → portosystemic shunting, splanchnic vasodilation → ascites, varices, encephalopathy

Clinical Presentation

  • Compensated: may be asymptomatic or have nonspecific fatigue, anorexia
  • Decompensated: ascites (abdominal distension), jaundice, spider angiomas, palmar erythema, caput medusae, hepatic encephalopathy (confusion, asterixis), variceal bleeding

Diagnostic Workup

Labs: AST/ALT ratio >1, thrombocytopenia (portal hypertension), prolonged PT/INR, low albumin. Liver ultrasound with Doppler: nodular surface, portal vein flow. FibroScan: measures liver stiffness. Endoscopy: screen for varices. Paracentesis: if ascites to rule out SBP.

Management Protocol

  1. Ascites: Sodium restriction <2g/day, diuretics (Spironolactone 100‑400 mg + Furosemide 40‑160 mg). Large volume paracentesis for refractory ascites
  2. Varices: Non‑selective beta‑blockers (Propranolol, Carvedilol) for primary prophylaxis; band ligation for secondary prophylaxis. Octreotide + endoscopic therapy for acute bleed
  3. Encephalopathy: Lactulose 30 mL BID titrated to 2‑3 soft stools/day; Rifaximin 550 mg BID
  4. HCC surveillance: abdominal ultrasound ± AFP every 6 months
  5. Liver transplantation evaluation if MELD ≥15 or decompensated

Complications & Prognosis

  • Variceal hemorrhage (mortality 15‑20% per episode)
  • Hepatorenal syndrome (Type 1: rapid; Type 2: slow)
  • Spontaneous bacterial peritonitis
  • Hepatocellular carcinoma

ICU Criteria

ICU admission if: acute variceal hemorrhage, hepatorenal syndrome, septic shock from SBP, or hepatic encephalopathy with airway compromise.

Clinical Vignette

A 58‑year‑old man with chronic hepatitis C presents with increasing abdominal girth and mild confusion. Exam reveals jaundice, ascites, and asterixis. Labs: bilirubin 4.5 mg/dL, INR 1.8, platelets 95,000. MELD score = 18.

Pearls & Pitfalls

  • Always perform diagnostic paracentesis in any cirrhotic patient with ascites admitted to the hospital – SBP is common and often asymptomatic.
  • Use lactulose for hepatic encephalopathy, but avoid oversedation – benzodiazepines worsen encephalopathy.

Discharge & Follow-Up

Monthly weight and ascites monitoring. Repeat variceal screening per guidelines. Adherence to lactulose and diuretics. Alcohol abstinence. Refer to hepatologist and transplant center.

Literature & Guidelines

AASLD 2024 Practice Guidance on Cirrhosis. PMID: 38723100.

Personal Clinical Notes