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==Background==

*A generally irreversible fibrotic scarring of the liver parenchyma resulting in liver failure
*The twelfth leading cause of death in men and women in 2013<ref>Heron M. Deaths: Leading Causes for 2013. Natl Vital Stat Rep 2016: 16;65(2):1-95.</ref>

===Causes===

*[[Special:MyLanguage/Hepatitis|Hepatitis]] chronic B and C
*Alcoholic liver disease
*[[Special:MyLanguage/Non-alcoholic steatohepatitis|Non-alcoholic steatohepatitis]]
*Drug induced (ie. [[Special:MyLanguage/Tylenol|Tylenol]]. [[Special:MyLanguage/amiodarone|amiodarone]], NRTIs])
*[[Special:MyLanguage/Congestive heart failure (CHF)|Cardiac Cirrhosis]]
*Primary biliary cirrhosis
*[[Special:MyLanguage/Primary sclerosing cholangitis|Primary sclerosing cholangitis]]
*[[Special:MyLanguage/Autoimmune hepatitis|Autoimmune hepatitis]]
*Alpha1 anti-trypsin Deficiency
*[[Special:MyLanguage/Cystic Fibrosis|Cystic Fibrosis]]

{{Sites of Portalcaval Anastomosis}}

==Clinical Features==

[[File:Jaundice08.jpg|thumb|Jaundice of the skin]]
[[File:SpiderAngioma.jpg|thumb|Spider angioma]]
[[File:Hepaticfailure.jpg|thumb|[[Special:MyLanguage/Ascites|Ascites]] secondary to cirrhosis.]]
*May be asymptomatic initially
*Malaise, [[Special:MyLanguage/weakness|weakness]] (from [[Special:MyLanguage/electrolyte derangements|electrolyte derangements]])
*[[Special:MyLanguage/Abdominal pain|Abdominal pain]]
*[[Special:MyLanguage/Ascites|Ascites]], [[Special:MyLanguage/SBP|SBP]] (fever, abdominal tenderness)
*[[Special:MyLanguage/Altered mental status|Altered mental status]] due to [[Special:MyLanguage/hepatic encephalopathy|hepatic encephalopathy]]
*[[Special:MyLanguage/liver disease induced coagulopathy|Coagulopathy]]
*[[Special:MyLanguage/GI bleed|GI bleed]]

==Differential Diagnosis==

{{DDX abdominal distention}}

{{Hepatomegaly DDX}}

==Evaluation==

[[File:Auscities.png|thumb|Ascites appearance on ultrasound]]
[[File:CirrhosisWithAscitesMark.png|thumb|Liver cirrhosis with ascites on CT]]

===Workup===

*CBC
*Chem 7
*PT/PTT
*[[Special:MyLanguage/LFTs|LFTs]] + lipase
*[[Special:MyLanguage/FAST|FAST]]
**See workup, if positive for [[Special:MyLanguage/ascites|ascites]]

===Diagnosis===

==Management==

'''Complications of cirrhosis'''
*[[Special:MyLanguage/Ascites|Ascites]]
*Esophageal [[Special:MyLanguage/varices|varices]]
*[[Special:MyLanguage/Hepatic encephalopathy|Hepatic encephalopathy]]
*[[Special:MyLanguage/Spontaneous bacterial peritonitis|Spontaneous bacterial peritonitis]]
*[[Special:MyLanguage/Hepatorenal syndrome|Hepatorenal syndrome]]
*Portal hypertension
*[[Special:MyLanguage/Upper gastrointestinal bleed|Upper gastrointestinal bleed]]
*[[Special:MyLanguage/Hepatocellular carcinoma|Hepatocellular carcinoma]]

'''Pain management in cirrhotic patients'''
*[[Special:MyLanguage/Acetaminophen|Acetaminophen]] is safe for short-term use at reduced dose of 2 grams total per day
*[[Special:MyLanguage/Gabapentin|Gabapentin]] or [[Special:MyLanguage/pregabalin|pregabalin]] for neuropathic pain
*Avoid [[Special:MyLanguage/NSAIDs|NSAIDs]]
*Avoid [[Special:MyLanguage/opioids|opioids]]
**unpredictable effects if liver function impaired due to hepatic metabolism
**if necessary, [[Special:MyLanguage/fentanyl|fentanyl]] or [[Special:MyLanguage/tramadol|tramadol]] probably safest

==Disposition==

*Often complex and should be based on presence/absence of acute complications
*If no complications present, discussion with patient's primary care provider or gastroenterologist recommended

==Prognosis==

===Child-Pugh Score[http://www.mdcalc.com/child-pugh-score-for-cirrhosis-mortality/ <ref>Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64</ref>]===

{| class="wikitable"
|-
! !! +1 !! +2 !! +3
|-
| Bilirubin|| <2mg/dL || 2-3mg/dL || >3 Mg/dL
|-
| Albumin || >3.5mg/dL || 2.8-3.5mg/dL || <2.8mg/dL
|-
| INR || <1.7 || 1.7-2.2 || >2.2
|-
|Ascites || No ascites || Ascites, medically controlled || Ascites, poorly controlled
|-
| Encephalopathy || No encephalopathy || Encephalopathy, medically controlled || Encephalopathy, poorly controlled
|}

*Score ≤ 7 = Class A = 100% and 85% one and two-year patient survival
*Score 7 - 9 = Class B = 80% and 60% one and two-year patient survival
*Score ≥ 10 = Class c = 45% and 35% one and two-year patient survival

===MELD Score[http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/ <ref>Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D'Amico G, Dickson ER, Kim WR. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001 Feb;33(2):464-70.</ref>]===

{| class="wikitable"
|-
! MELD-Na Score !! 3-month mortality
|-
| 40 || 71.3%
|-
| 30-39 || 52.6%
|-
| 20-29 || 19.6%
|-
| 10-19 || 6.0%
|-
| <9 || 1.9%
|}

==See Also==

*[[Special:MyLanguage/Viral hepatitis|Viral hepatitis]]
*[[Special:MyLanguage/Acute hepatic failure|Acute hepatic failure]]
*[[Special:MyLanguage/Jaundice|Jaundice]]
*[[Special:MyLanguage/Ascites|Ascites]]

==External Links==

==References==

<references/>

[[Category:GI]]

Cirrhosis/en - Revision history

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