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Cirrhosis Basics for the Physician Assistant Exam

Any hepatic process, especially hepatitis or long-standing alcoholism over time, causes cirrhosis of the liver. Cirrhosis is not reversible. For the Physician Assistant Exam (PANCE), you will need to be familiar with various aspects of cirrhosis.

Because the liver is responsible for regulating metabolism, processing medications, and processing the body’s various hormones, many things can change when cirrhosis is present. Men can develop gynecomastia (also known as “man-boobs”). People with cirrhosis feel tired and weak.

From an acid-base perspective, chronic liver cirrhosis can cause a respiratory alkalosis. The liver also regenerates bicarbonate, so at very late stages of liver disease, a metabolic acidosis can be present.

People with cirrhosis can have problems with blood clotting, which is manifested by an elevated PT/INR. If there’s significant portal hypertension and splenomegaly, then leukopenia and thrombocytopenia may also be present. Liver disease itself can cause a macrocytic anemia.

As cirrhosis progresses, you see elevation in the portal venous pressures. Ascites occurs when the portal venous pressures are greater than 30 mmHg. For chronic compensated cirrhosis, the treatment is sodium restriction, and if ascites is present, the use of spironolactone (Aldactone) and/or furosemide (Lasix).

It doesn’t take much for someone to go from a compensated state of cirrhosis to a decompensated state. GI bleeding, spontaneous bacterial peritonitis (SBP), and bacteremia all can cause the liver to decompensate. In decompensated cirrhosis or end-stage liver disease, you may see some or all of the following:

  • Hepatic encephalopathy, which is due to an elevated NH3 level (hyperammonemia): The treatments include lactulose and rifaximin (Xifaxan) second line.

  • Bleeding secondary to hypoprothrombinemia: Oral and/or subcutaneous therapies are unlikely to be effective with a cirrhotic liver. In this situation, you may need to give fresh frozen plasma.

  • An increased risk for renal failure: Examples include prerenal azotemia, acute tubular necrosis (ATN), and the hepatorenal syndrome (HRS).

  • Hypotension: As the liver fails, the systemic vascular resistance drops, and consequently, so does blood pressure.

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