Jan 2013 - When the Spleen Gets Tough, the Varices Get Going
In this era of personalized medicine, it is necessary to stratify different risk groups among patients with cirrhosis.
As recently proposed, a revised staging of cirrhosis should start with its main classification of compensated
and decompensated cirrhosis, 2 separate entities with different prognostic significance
Decompensated cirrhosis is defined by the presence of complications that are mostly secondary to portal hypertension: Ascites, variceal hemorrhage, and/or hepatic encephalopathy.
Compensated cirrhosis would in turn be composed of 2 substages: Without varices or with varices.
These 2 substages of compensated cirrhosis also have different prognostic significance; patients without varices
have a significantly better survival than those with varices.
In compensated patients without varices, the degree of portal hypertension predicts the development of both varices and
decompensation....... continue reading.....
STAGES OF DISEASE PROGRESSION
Like other liver diseases, HCV disease progresses in stages. The usual progression is from inflammation to fibrosis to cirrhosis. Cirrhosis can progress to end-stage liver disease and/or can give rise to liver cancer.
Prevalence and Challenges of Liver Diseases in Patients with Chronic Hepatitis C Virus Infection
Progressive hepatic fibrosis leading to cirrhosis is the major complication of chronic HCV infection and accounts for almost all HCV-related morbidity and mortality. Early studies suggested little, if any, fibrosis progression during the first decade of infection, followed by a slow, regular progression during the next 15 years, increasing to an intermediate rate during the subsequent decade. In a German cohort study of 1833 women infected with HCV-contaminated immunoglobulin, 0.5% of patients developed cirrhosis after 25 years. Similarly, in a study of 376 HCV-infected women conducted by the Irish Hepatology Research Group, 51% of patients had fibrosis after 17 years, but only 2% had probable/definite cirrhosis. These estimates of cirrhosis rates are considerably lower than those from the US multicohort study and the widely cited US military study (approximately 35%) Fibrosis outcomes of 184 women from the same cohort were followed up for the subsequent 5 years; 49% showed no change in fibrosis, 24% showed regression, and 27% showed progression.
Recent data reinforce the potential for severe liver disease to develop in some patients. Among 485 plasma donors infected during the early 1970s, 34% had stage F3/F4 fibrosis (bridging fibrosis), cirrhosis, or HCC after 31 years; their 35-year cumulative survival was 84% versus 91%–95% for the general population Similarly, a study of 300 black and white Americans with untreated HCV infection found that 29% of patients had stage F3/F4 fibrosis after 20 years, and 4.7% had confirmed cirrhosis. It should be noted, however, that these studies could have selected patients with severe disease.
Read Full Data..........
Liver inflammation refers to the presence of special cells called inflammatory cells in the liver. Chronic inflammation is inflammation that persists over a long period of time. It leads to changes in liver structure, slowed blood circulation, and the death of liver cells (necrosis). Chronic inflammation eventually causes scar tissue to form, a condition known as fibrosis. By controlling liver inflammation, you can control progression to fibrosis.
Fibrosis is the harmful outcome of chronic inflammation. Fibrosis is scar tissue that forms as a result of chronic inflammation and/or extensive liver cell death. Your health care provider uses the amount of fibrosis in your liver as one way of evaluating how quickly your disease appears to be progressing. Having knowledge of approximately when you were initially infected with HCV is a great help in determining your rate of disease progression
When fibrosis becomes widespread and has progressed to the point where the internal structure of the liver has become abnormal, fibrosis has progressed to cirrhosis. Cirrhosis is the result of long term liver damage caused by chronic inflammation and liver cell death. The causes of cirrhosis include viral hepatitis, excessive intake of alcohol, inherited diseases, and hemochromatosis (abnormal handling of iron by the body).
Cirrhosis is accompanied by a reduction in blood supply to the liver. The loss of healthy liver tissue and the reduced blood supply can lead to abnormalities in liver function. Even when liver disease has progressed to cirrhosis, it may still be possible for the damage to be at least partially reversed if the underlying cause can be eliminated. Cirrhosis progression can usually be slowed or even stopped with treatment.
The onset of cirrhosis is usually silent, with few specific symptoms to identify this development in the liver. As scarring (fibrosis) and destruction continue, some of the following signs and symptoms may occur: loss of appetite, nausea and/or vomiting, weight loss, change in liver size, gallstones, itching, and jaundice. However, a large number of people live many, many years with cirrhosis without any decompensation or symptoms.
It is important to know that once cirrhosis develops, it is critical to avoid further progression of the disease. The consumption of alcohol in any form, including such things as certain mouthwashes and cough medicines, must be completely avoided by people with cirrhosis.
Grading and Staging Liver Disease on Biopsy :
Grading describes the degree of inflammation and necrosis.
One of the two mechanisms by which cell death occurs (the other being the physiological process of apoptosis. Necrosis is caused by the progressive degradative action of enzymes and is generally associated with severe cellular trauma. It is characterized by mitochondrial swelling, nuclear flocculation, and uncontrolled cell lysis. Decay or death of one or more cells, resulting from irreversible damage. Death of living tissue; death of a portion of tissue differentially affected by local injury (as loss of blood supply,burning, corrosion, or the local lesion of a disease
Grade 0 no inflammation
Grade 1 peri-portal inflammation no hepatocellular necrosis
Grade 2 inflammation with mild interface hepatitis
Grade 3 severe portal inflammation with moderate interface hepatitis
Grade 4 marked inflammation with severe interface hepatitis
Grade 0 no inflammation
Grade 1 minimal, no necrosis (inflammatory cells within the lobule)
Grade 2 moderate inflammatory cells with occasional liver cell necrosis
Grade 3 marked inflammation with severe focal liver cell necrosis
Grade 4 extensive inflammation with bridging necrosis
Staging describes the degree of fibrosis (scarring).
Stage 1 none or mild peri-portal fibrosis
Stage 2 peri-portal fibrosis with/without extension and portal-portal bridging
Stage 3 portal-central bridges but no nodular formation
Stage 4 probable or definite cirrhosis
Hepatitis has 4 stages. Stage 4 Hepatitis = Cirrhosis.
There's 3 stages of Cirrhosis:
Stage A ("compensated"; not too sick)
Stage B (beginning to decompensate; complications beginning to appear)
Stage C ("decompensated"; end stage)
Doctors use something called a Child-Turcotte-Pugh (CTP) score to see what Stage of cirrhosis that a person is in.
The CTP Score is based on FIVE QUESTIONS.
You receive a point value (score) for each of the answers.
Here's how it works:
1. Total Serum Bilirubin
.....if Bilirubin is <2 mg/dl: score 1 point
.....if Bilirubin is 2-3 mg/dl: score 2 points
.....if Bilirubin is >3 mg/dl: score 3 points
2. Serum Albumin
.....if Albumin is >3.5 g/dl: score 1 point
.....if Albumin is 2.8 to 3.5 g/dl: score 2 points
.....if Albumin is <2.8 g/dl: score 3 points
.....if INR is <1.70: score 1 point
.....if INR is 1.71 to 2.20: score 2 points
.....if INR is >2.20: score 3 points
.....No Ascites: score 1 point
.....Ascites controlled medically: score 2 points
.....Ascites poorly controlled: score 3 points
.....No Encephalopathy: score 1 point
.....Encephalopathy controlled medically: score 2 points
.....Encephalopathy poorly controlled: score 3 points
Total your score.
Sum total score gives grades of:
5 to 6 points = Stage A Cirrhosis
7 to 9 points = Stage B Cirrhosis
10 to 15 points = Stage C Cirrhosis
A person has to be at least Stage B or Stage C, in order to get referred for an "Evaluation" for a chance at the liver transplant waiting list. (Stage A Cirrhosis is not sick enough to think about a referral for an evaluation).
CTP scores and MELD scores are two completely different things.
MELD scores are use for allocation of donor livers
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