INTRODUCTION

 Liver cirrhosis is a patologic condition described as a

progressive end-stage liver fibrosis.

 Marked with liver architecture distortion, along with

regenerative nodules formation

 “Shrinkage of the liver”

CLASSIFICATION
 Compensated Cirrhosis
 Absence of marked clinical symptoms

 Decompensated Cirrhosis
 Marked Clinical Symptoms :
1. Liver Failure
2. Portal Hypertension
Causes of Cirrhosis
 Viral hepatitis; B, D, and C
 Alcohol
 Metabolic
Haemochromatosis
Wilson’s disease
Alpha-1-antitrypsin deficiency
 Chronic biliary obstruction
Extrahepatic biliary obstruction
Intrahepatic biliary obstruction
 Venous outflow obstruction
Veno-occlusive disease
Budd-Chiari syndrome
Cardiac failure
 Autoimmune chronic active hepatitis
 Drug and toxins
SIGNS & SYMPTOMS
 Compensated Cirrhosis
Asymptomatic

 Decompensated Cirrhosis
Signs : spider nevi, palmar erythem, icterus,
gynecomastia (♂), splenomegali, ascites & edema,
esophageal varices, muscular atrophy, etc

Symptoms : UGI bleeding, weight loss, anorexia,

menstrual disturbances (♀), coma (severe)
DIAGNOSIS
 Clinical
Liver failure + Portal hypertension
 Laboratory : anemia, thrombocytopenia,
SGOT/SGPT may be normal,
ALP & GGT elevated, prolonged PT
hypoalbuminemia (inverse Alb/Glo)
 USG : liver fibrosis, ascites, splenomegali,
portal vein dilatation, irreguler
Mass  HCC!
Portal Hypertension Syndrome
Continuing Liver damage

Nodular regeneration

Fibrosis

Increased sinusoidal
pressure

Portal Hypertension

Splancnic vasodilatation Increased gastroesophageal

collateral

Decreased effective blood Formation of

volume oesophagogastric varices

Increased sodium retention Variceal rupture

Ascites Variceal bleeding

TREATMENT
 Restriction activity
 Water and Sodium restriction
 Aldosterone antagonist : Spironolactone
 Loop diuretic : Furosemide
 Others : depends on complication(s)
Complications of Cirrhosis
 Variceal bleeding
 Ascites, refractory ascites
 Hepatorenal syndrome
 Hepatic encephalopathy
 Spontaneous bacterial peritonitis
 Hepatocelluler carcinoma
A. Bleeding from – varises is reported in about 20 – 60 %
of case whit cirrhosis.
B. Mortality of the first bleeding episode is around 50 %

Preventime measure rationalto avoid development

of Varices and bleeding (Primary proplylaris).
C. Up to 70 % Of Patient Whoo do not receive treatment
die within 1 year of the initial bleeding episode

The Efforts in preventing bleeding seems to be

crucial (secondary, prophylaxis)
Consensus in Portal Hypertension Baveno III
Monitoring for the Development of Varices in the
Portal Hypertensive Patient.
1. All cirrhotic patients should be screened for the
presence of varices at the time of the initial
diagnosis of cirrhosis.
2. In compensated patients without varices, endoscopy
should be repeated at 2-3 year intervals to
evaluate the development of varices.
3. In compensated patients with small varices,
endoscopyshould be repeated at –2 year intervals to
evaluate progression of varices.
4. There is no indication for subsequent evaluations
once large varices are detected.
Algorithm for cirrhosis Without Bleeding

Algorithm For
Cirrhosis Without
Bleeding
Cirrhosis
Established

Upper Endoscopy

No varices Small or Medium Large Varices

Varices

Observe Observe Primary Bleeding

(2 – 3 years Evaluation) (1 – 2 years Evaluation)
Prophylaxis
Reguler Interval
Usually one week
 Non Selectne Blockers
Propanolol
 Ligation
Dosis dan cara pemberian obat-obat vasoaktif pada
perdarahan varises
Obat Cara pemberian Dosis Lama
pemberian
Vasopressin VP: i.v infus VP: 48 jam
(VP) + NG: 0,4UU/menit
Nitroglyserin percutaneus,
(NG) bolus

Terlipressin i.v, bolus 2 mg/4 jam 2-5 hari

selama 24-48
jam pertama,
kemudian 1
mg/ 4 jam
Somatostatin i.v bolus dan 250 ug diikuti 2-5 hari
infus 250-500 ug/jam
Octreotide i.v, bolus dan 50 ug diikuti 2-5 hari
infus 50 ug/jam
Cirrhotic patients at high risk of SBP
 Hospitalized cirrhotic patients with ascites and low ascitic
fluid total protein (< 1 g/dl)
 Cirrhotic patients with gastrointestinal hemorrhage
 Cirrhotic patients with low ascitic fluid total protein (< 1
g/dL) and / or high serum bilirubin (>2.5 mg/dl)
 Survivors of an episode of SBP.
 Diagnosis Peritonitis Bakterialis Spontan

Pasien sirosis hati dengan asites Pungsi asites

Nyeri perut panas Gejala menyertai:

Syok, perdarahan, gangguan
kesadaran, gangguan
motilitas, hipotensi, dll
Asimtomatik.

Pungsi asites:
periksa: PMN
Kultur

Sel PMN > 250 Sel PMN < 250

Ulangi pungsi
24 jam
Kultur + Monomikrobial
Kultur + Monomikrobial

PBS
BMNN
(Bakterasites Monomikrobial
Non-Neutrosistik)
 Penatalaksanaan Peritonitis Bakterialis Spontan

PBS simtomatik Profilaksis PBS

Ofloksasin
Antibiotik pilihan : Siprofloksasin
Sefotaksim 1-2 gram/hari selama 5-7 hari Dosis standar
Amoksisilin+Asam klavulanat selama 5-7 hari 5-7 hari

Parasentesis ulang setelah 24 jam

antibiotik

Sel PMN Sel PMN

Antibiotik
Ganti antibiotik
diteruskan
 Pathogenesis of Hepatorenal Syndrome

Cirrhosis

Sinusoidal portal
hypertension

Splanchnic vasodilatation

Arterial underfilling

Reduced renal Baroreceptor-mediated Increased intrarenal

vasodilator factors activation of systemic vasoconstriction
Vasoconstriction factors factors

Renal vasoconstriction

Hepatorenal syndrome
 Treatment of HCC depends on
1. Local resources
2. Stage of the disease
3. Presence of cirrhosis

 Liver Transplantation
 Hepatic resection  treatment of choice for
the few patients with HCC and normal liver.
 Trans Arterial Chemo Embolization
 Cytostatica
 Interferon
Five years survival of pts with HCC treated by transplantation in 82
Europeans centers between 1988 and june 1994
 Indication to transplantation Patients % Alive

HCC with Cirrhosis 361 46

HCC without cirrhosis 446 34
Cirrhosis with HCC 176 54

p = 0.0004
 KESIMPULAN
 Sirosis hati, stadium terakhir dari penyakit hati kronis
yang manifestasi kliniknya mengenai berbagai macam
sistem dan organ tubuh.
 Komplikasi yang tersering adalah: Asites, Perdarahan
varises, SBP, Ensepalopati hepatik, HCC.
 Penanganannya masih merupakan masalah yang
menyulitkan
 Pengelolaan yang menyeluruh adalah hal yang terbaik