Tuesday, 3 December 2013

Cirrhosis - The Diagnosis

Cirrhosis is defined as a condition of irreversible scarring liver as a result of liver tissue by fibrosis due to final phase of chronic liver diseases of that can lead to poor function of the liver and liver failure. According to the statistics, Number of discharges with chronic liver disease or cirrhosis as the first-listed diagnosis: 101,000 in 2009 and Deaths per 100,000 population: 10.3 in 2010(a). Hepatitis B infection cause of the disease is very prevalent in South-East Asia.
After recording the physical examination, including exanination of the liver for  enlargement (indication of early stahe of cirrhosis), hardening (indicated the end stge of the disease), symptoms of sweeling (indication of fluid retention) and family history, if you are suspective to have any form of liver diseases, the tests which your doctor orders may include
1. Blood test
The aim of the blood test is to measure the liver enzymes associated with liver function, including serum albumin concentration for the measuremant of the protein in the blood, Prothrombin time (PT) for the blood cloted time, Alkaline phosphatase (ALP) for the blokage of bible duct, Bilirubin (the yellow pigment are indication of liver damage)for the damage of liver.
2. Image tests
a. Magnetic resonance imaging (MRI)
In the study to evaluate the clinical practical value of apparent diffusion coefficient (ADC) measurements based on diffusion-weighted MR imaging (DWI) for quantification of liver fibrosis and inflammation for hepatitis viral infection, found that the DWI measurement of hepatic ADC can be used to quantify liver fibrosis and inflammation. It will be a new approach for early diagnosis and therapeutic follow-up of hepatic fibrosis(43).
Other study indicated that DWI is proved to be a useful clinical tool in the quantitative evaluation of liver fibrosis and in the prediction of the process of liver fibrosis with the recommendable b value (500 s/mm2)(44).

b.  Computed tomography (CT)
The CTA was much more sensitive in detecting haemodynamic changes in the cirrhotic liver than CTAP, conventional CT and sinusoidal-phased hepatic angiography. Further study is required to clarify the mechanism of inhomogeneous enhancement on CTA and homogeneous enhancement on CTAP seen in cirrhosis, according to the study by the National Cancer Center Hospital(45).
 Other report of Regenerative nodules in cirrhotic liver are visualized as enhancing nodules surrounded by lower attenuation thin septa at CTAP and nonenhancing nodules surrounded by enhancing fibrous septa at CTHA. CTHA is more sensitive than CTAP in depicting regenerative nodules (P < .005)(46).

c. Ultrasound
Ultrasound examination was performed in 80 hemodialysis (HD) patients divided into two groups. The first group consisted of 37 (46.3%) patients with US greater than 66, indicating the presence of compensated liver cirrhosis. The second group included 43 (53.7%) patients without liver cirrhosis, with US equal to or less than 66. The value of liver morphology was significantly higher,with chronic hepatitis C in order to determine the ultrasound predictors of compensated liver cirrhosis, found that
Ultrasound examination could be used for non-invasive diagnosis of compensated liver cirrhosis, with accurate estimation of the disease severity in HD patients with chronic hepatitis C(47).

3. Liver biopsy
In liver biopsy, a sample of the liver is withdrawn and examined under microscope to comfirm or rule out the disease. In the study to summarize the role of liver biopsy, transient elastography and hepatic venous pressure gradient (HVPG) in the diagnosis and monitoring of patients with liver cirrhosis, found that Transient elastography has some value for the prediction of clinically significant portal hypertension, but a large proportion of patients have non-diagnostic values. It has also some value for the diagnosis of varices, but non-invasive markers cannot substitute endoscopic screening in cirrhosis. Better dynamic, easily repeatable non-invasive tools are needed to monitor compensated cirrhosis(48).  But other study indicated that Needle biopsy of the liver is considered the "gold-standard" for diagnosis of hepatic fibrosis and cirrhosis. However, it is not risk-free, lacks accuracy, and is poorly accepted by some patients, and suggested that Transient elastography is reliable in detecting moderate to severe fibrosis and cirrhosis and in ruling out cirrhosis, but is less reliable in ruling out moderate fibrosis. Composite scores based on blood assay values and complex calculations are unreliable when at least one of the score components is influenced by intercurrent conditions. FibroTest, FibroMeter and Hepascore have been tested in several thousand patients with chronic hepatitis C. With the manufacturers' recommended cutoff values, FibroTest identifies about 70% of patients with histological signs of moderate to severe fibrosis and about 90% of patients with histological signs of cirrhosis. It can reliably diagnose or rule out moderate fibrosis, and diagnose cirrhosis. It is also very reliable in ruling out cirrhosis. Hepascore has similar diagnostic performance. FibroMeter has been less extensively evaluated but also seems to have diagnostic performance similar to that of FibroTest(49).

4. Endoscopy
Endoscopy may be the best choice for patients  diagnosed with mild-to-moderate cirrhosis in order to screen for esophageal varices. According to the study by Institute of Liver and Biliary Sciences, in the study of Patients with cirrhosis who undergo endoscopy under sedation could be at increased risk of complications, found that Propofol is safe in patients with cirrhosis and the critical flicker frequency (CFF) is a useful tool for the assessment of recovery from sedation in these patients(50).

5. Paracentesis
If there is evidence of fluid retention, paracentesis may be necessary to determine its cause. According to study, ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites for the effective of the treatments(51).

 6. Etc.
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(a) http://www.cdc.gov/nchs/fastats/liverdis.htm
(43) http://www.ncbi.nlm.nih.gov/pubmed/19862980
(44) http://www.ncbi.nlm.nih.gov/pubmed/18853855
(45) http://www.ncbi.nlm.nih.gov/pubmed/10535474
(46) http://www.ncbi.nlm.nih.gov/pubmed/10207429
(47) http://www.ncbi.nlm.nih.gov/pubmed/23354188
(48) http://www.ncbi.nlm.nih.gov/pubmed/22560536.
(49) http://www.ncbi.nlm.nih.gov/pubmed/20455345
(50) http://www.ncbi.nlm.nih.gov/pubmed/21547878
(51) http://www.ncbi.nlm.nih.gov/pubmed/21455322

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