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PATHOPHYSIOLOGY OF GASTROINTESTINAL SYSTEM SMS 2044 PRESENTATION OF LIVER CIRRHOSISBY: 1. NUR AMELIA HUSNA BT HASBULLAH 012006051405 2. NORMAINAH BT A.RAHMAN 012006051150 3. NUR SYARINA BT ABD LAZIZ 012006050754 4. IZZATUL AMIRAH BT AHMAD MAZLAN 012006050873 5. MOHAMED SHEIK ABDULLAH 012006110162

DEFINITION A degenerative disease of the liver in which hepatic tissue is replaced with connective tissue, commonly a result of chronic alcoholism. Term that refers to a group of chronic diseases of the liver in which normal liver cells are damaged and replaced by scar tissue (fibrosis), decreasing the amount of normal liver tissue. A group of liver d/s marked by interstitial inflammation of the liver, fibrosis, loss of normal hepatic architecture, and nodular regeneration.

TYPES OF LIVER CIRRHOSIS

Alcoholic cirrhosis Nonalcoholic fatty liver disease Hepatitis-related cirrhosis Cryptogenic cirrhosis Primary biliary cirrhosis Primary sclerosing chlangitis Secondary biliary cirrhosis Hemochromatosis Wilsons disease Alpha-1 antitrypsin

CAUSESAlcoholic liver disease. Chronic hepatitis C. Chronic hepatitis B and D. Autoimmune hepatitis. Inherited diseases Nonalcoholic steatohepatitis (NASH). Blocked bile ducts Drugs, toxins, and infections.

PATHOPHYSIOLOGY 2 primary ingredients exist: hepatic fibrosis and regenerating liver cells 1- in response to injury & loss growth regulators induce hepatocellular hyperplasia (producing regenerating nodules)& arterial growth (angiogenesis)growth regulators are cytokines & hepatic growth factors ( e.g. epithelial growth factor, hepatocyte growth factor, transforming growth factor- , tumor necrosis factor)

2- Insulin, glucagon & patterns of intrahepatic blood flow determine how and where nodules develop. 3- Angiogenesis produces new vessels within the fibrous sheath that surrounds nodules.

PATHOHYSIOLOGY4- These bridges connect the hepatic artery & portal vein hepatic venules, restoring the intrahepatic circulatory pathways. 5- Interconnecting vessels provide relatively low volume, high pressure venous drainage that cannot accommodate as much blood volume as normal. 6- As a result, portal vein pressure .Distortions in blood flow contribute to portal hypertension, which because the regenerating nodules compress hepatic venules.

The progression rate from fibrosis to cirrhosis & the morphology of cirrhosis vary from person to person.

SIGNS AND SYMPTOMS Jaundice exhaustion fatigue loss of appetite nausea weakness weight loss abdominal pain spider-like blood vessels (spider angiomas) that develop on the skin

COMPLICATION Edema and ascites Spontaneous bacterial peritonitis (SBP) Bleeding from esophageal varices Hepatic encephalopathy Hepatorenal syndrome Hepatopulmonary syndrome Hypersplenism Liver cancer (hepatocellular carcinoma)

COMPLICATION Edema and ascites o the kidneys retain salt and water in the body due to severe cirrhosis o excess salt and water will accumulates in the tissue beneath the skin of the ankles and legs because of the effect of gravity when standing or sitting o This is called edema or pitting edema o As cirrhosis worsens more salt and water are retained, fluid also may accumulate in the abdominal cavity between the abdominal wall and the abdominal organs o This cause swelling(ascites) in the abdominal region

COMPLICATION Spontaneous bacterial peritonitis (SBP) o SBP is a life- threatening complication o Some patients with SBP have no symptoms, while others have fever, chills, abdominal pain and tenderness, diarrhea, and worsening ascites o the fluid that collects in the abdomen is unable to resist infection,so bacteria find their way from the intestine into the ascites

COMPLICATION Bleeding from esophageal varices o Portal hypertenion occur due to scar tissue in cirrhosis blocks the flow of blood returning to the heart from the intestines o causes blood to flow around the liver through veins with lower pressure to reach the heart o As a result of the increased flow of blood and the resulting increase in pressure, the veins in the lower esophagus and upper stomach expand and then are referred to as esophageal and gastric varices o higher the portal pressure, the larger the varices and the more risk a patient is to bleed from the varices into the esophagus or stomach. o Symptoms of bleeding from varices include vomiting blood, passing stool that is black and tarry due to changes in the blood, and orthostatic dizziness or fainting

COMPLICATION Hepatic encephalopathy o toxic substances cannot be removed by the liver cells due to abnormalities instead, the toxic substances accumulate in the blood o When the toxic substances accumulate sufficiently in the blood, the function of the brain is impaired, a condition called hepatic encephalopathy o Sleeping during the day rather than at night (reversal of the normal sleep pattern) is among the earliest symptoms of hepatic encephalopathy o Other symptoms include irritability, inability to concentrate or perform calculations, loss of memory, confusion, or depressed levels of consciousness

COMPLICATION Hepatorenal syndrome o This syndrome is a serious complication in which the function of the kidneys is reduced due to changes in the way the blood flows through the kidneys themselves o defined as progressive failure of the kidneys to clear substances from the blood and produce adequate amounts of urine o are two types of hepatorenal syndrome in which one type occurs gradually over months and the other occurs rapidly over a week or two.

COMPLICATION Hepatopulmonary syndrome o some patients with advanced cirrhosis can develop the hepatopulmonary syndrome o patients can experience difficulty breathing because certain hormones released in advanced cirrhosis cause the lungs to function abnormally o the lung got not enough blood flows through the small blood vessels in the lungs that are in contact with the alveoli (air sacs) of the lungs. Blood flowing through the lungs is shunted around the alveoli and cannot pick up enough oxygen from the air in the alveoli o As a result the patient experiences shortness of breath, particularly with exertion.

COMPLICATION Hypersplenism o the pressure in the portal vein rises in cirrhosis, it increasingly blocks the flow of blood from the spleen thus the blood "backs-up" and accumulates in the spleen, as the spleen swells in size o As the spleen enlarges, it filters out more and more of the blood cells and platelets until their numbers in the blood are reduced o it is associated with a low red blood cell count (anemia), low white blood cell count (leucopenia), and/or a low platelet count (thrombocytopenia

COMPLICATION Liver cancer (hepatocellular carcinoma) o One of the causes to cirrhosis o 2 types of hepatocellular carcinoma ; primary and secondary o Primary refers to the fact that the tumor originates in the liver while a secondary liver cancer is one that originates elsewhere in the body and spreads (metastasizes) to the liver. o most common symptoms and signs of primary liver cancer are abdominal pain and swelling, an enlarged liver, weight loss, and fever

INVESTIGATION biopsy of the liver the history, physical examination, or routine testing history of excessive and prolonged intake of alcohol, a history of intravenous drug abuse, or a history of hepatitis Computerized tomography (CT or CAT) or magnetic resonance imaging (MRI) scans and ultrasound examinations

TREATMENT Treatment of cirrhosis includes : 1. preventing further damage to the liver 2. treating the complications of cirrhosis 3. preventing liver cancer or detecting it early 4. liver transplantation.

TREATMENT1. o o o o o o o Preventing further damage to the liver Consume a balanced diet and one multivitamin daily Avoid drugs (including alcohol) that cause liver damage Avoid nonsteroidal antiinflammatory drugs Eradicate hepatitis B and hepatitis C virus by using anti-viral medications Remove blood from patients with hemochromatosis Suppress the immune system with drugs such as prednisone and azathioprine Immunize patients with cirrhosis against infection with hepatitis A and B to prevent a serious deterioration in liver function

TREATMENT2. o o o Treating the complications of cirrhosis restrict dietary salt (sodium) and fluid to decrease edema and ascites transjugular intravenous portosystemic shunting use as a treatment for refractory ascites medications and procedures to decrease the pressure in the portal vein and procedures to destroy the varices such as Propranolol (Inderal), a beta blocker and Octreotide (Sandostatin) sclerotherapy or band ligation A surgical operation to create a shunt (passage) from the high-pressure portal vein to veins with lower pressure low protein diet and oral lactulose blood transfusions or treatment with erythropoietin or epoetin alfa

o o o o

TREATMENT3. Prevention and early detection of liver cancer

o screened yearly or every six months with ultrasound examination of the liver and measurements of cancer-produced proteins in the blood, e.g. alpha fetoprotein o Liver transplant

THANK YOU FOR YOUR ATTENTION