www.turner-white.com Gastroenterology Volume 15, Part 2 1
Liver Cirrhosis and Its Associated Complications
Eric S. Orman, MD, MSCR
Liver cirrhosis is a histologic entity characterized
by fibrous septae surrounding regenerative nodules
of hepatocytes. It is the end-stage of progressive
hepatic fibrosis and can be caused by a variety of
insults, most commonly viral hepatitis, alcohol, and
nonalcoholic steatohepatitis. The resulting architectural distortion that is seen in end-stage disease
leads to increased resistance to portal blood flow
and increased portal collateral circulation, both
of which contribute to portal hypertension. Portal
hypertension in turn leads to the clinical manifestations of end-stage liver disease: ascites, varices,
and hepatic encephalopathy. These features carry
significant associated morbidity and mortality, and
their appearance heralds a poor prognosis. Management of these conditions is a common clinical
challenge and an important component of the care
of patients with chronic liver disease.
Initial Presentation and History
A 56-year-old man with chronic hepatitis C
virus infection presents with a 2-month history of
malaise, progressive abdominal distention, early
satiety, and weight gain of 10 kg. In the past week,
he has noted orthopnea as well as poorly local-
ized abdominal discomfort that is worse in a sit-
ting position. He endorses low-grade nausea but
no vomiting, and there have been no changes in
his bowel movements. He denies chest pain, ex-
ertional dyspnea, and lower extremity edema. He
has tried acetaminophen and ibuprofen with little
In addition to his hepatitis C, which has not been
previously treated, he has hypertension and well-controlled diabetes. There is a prior history of heavy
alcohol abuse, between 6 and 12 bottles of beer
daily for 20 to 25 years. He has been abstinent from
alcohol for the past 8 years, and there is no history
of illicit drug use. Current medications include low-dose aspirin, metoprolol, and metformin.
On exam, he is chronically ill appearing but in
no acute distress. He is afebrile, with a pulse of
80 beats/min and blood pressure of 112/70 mm Hg.
Room air oxygen saturation is 99%. There is noticeable temporal wasting but no jaundice. Lungs
are clear to auscultation throughout. The abdomen
is grossly distended, with shifting dullness, and
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