GIT j club cirrhosis women.

1. Kurdistan Board GEH J Club 2016
Supervised by:
Dr. Mohamed Alshekhani
Professor in Medicine
MBChB-CABM-FRCP-EBGH

2. Introduction:
• Cirrhosis is an important public health concern with prevalence
of 0.27% adults , 27% women, lower closely related to lower
prevalence of HBV&HCV, alcohol & iron overload.
• NASH ? more prevalent in women that in men.
• knowledge of sex differences in liver disease prevalence, natural
history& treatment is important to:
• Optimize individual long-term outcomes.
• Manage unique issues in women with regard to conception,
pregnancy & postpartum care.

3. SEX DIFFERENCES :Chronic HCV
• Spontaneous clearance of the virus occurs more frequently among
women than men; 37% vs 21%.
• Female sex is also a protective factor for the progression of liver
fibrosis in premenopausal but not postmenopausal women with
HCV, through protective effect of estrogens.
• Among postmenopausal women, there was less advanced fibrosis
in those who had received hormone replacement therapy
• Other factors; lower frequency of cofactors, like alcohol use&
HIV.
• Tolerability of ribavirin, reduced in women due to lower Hb.
• The teratogenicity associated with ribavirin should also be
considered in every woman of child-bearing age.
• No sex differences identified in DAA therapy.

4. SEX DIFFERENCES :Chronic HBV
• Women have a lower rate of progression to cirrhosis and HCC
then men *3-6 due to higher prevalence of cofactors for disease
progression;alcohol use, iron overload, HCV
• A higher frequency of HBV flares in men compared with women,
persisted even after adjustment for confounders; age, HBV DNA
level, fibrosis stage and presence of precore &basal core promoter
variants.
• Reactivation of HBV following HBeAg seroconversion happen
more often in men than in women , may contribute to the higher
prevalence of HBV-cirrhosis & HCV in men.
• Treatment for HBV do not differ for men vs women, except ULN
for ALT are 19 U/L for women, 30 U/L for men.
• Women with ALT >38 U/L (2 times ULN)& persistently elevated
HBV DNA are potential candidates for antiviral therapy.
• For women with cirrhosis, antiviral therapy is recommended if
HBV viremia is present, regardless of ALT.

5. SEX DIFFERENCES :Alco LD
• Women consume less alcohol than men, drink less frequently,
&less likely to be hazardous drinkers.
• Women who drink alcohol develop more liver problems than
men. Because women express less gastric alcohol dehydrogenase&
have less fat tissue&less total water than men, so smaller volume
of distribution of alcohol.
• The level of alcohol intake for liver damage 7-13 drinks / week for
women & 14- 27 drinks / week for men, so women should keep
alcohol intake <1 drink / day or 7 / week& If have another cause
for chronic liver disease;HCV or HBV,abstinence recommended.
• Women tend to do better after outpatient treatment & achieve
more sustained abstinence then men & lower mortality
• No sex difference in the treatment of alcohol dependence with
pharmacologic agents (acamprosate / naltrexone).

6. SEX DIFFERENCES :NAFLD
• NAFLD appears to be less common in white women but not in
black & Hispanic women.
• Among women; advancing age, postmenopause,more features of
MS linked with presence of NAFLD.
• ? Sex differences in the natural history of NAFLD.
• Age & hepatic inflammation were predictors of fibrosis, but not
female sex.
• Greater severity of liver fibrosis in men vs premenopausal
women, not postmenopausal women,due to sex hormones.
• HRT reduce ALT in women & oral contraceptives users had
50% lower NAFLD, no longer significant after adjusting for
obesity.

7. SEX DIFFERENCES :Prognosis
• Female inconsistency associated with mortality in cirrhosis with a
reduced risk of mortality in patients with compensated cirrhosis.
• Heterogeneity in treatable causes of cirrhosis, different times to
diagnosis/or difference in adherence to cirrhosis management are
influencing outcomes in women versus men with cirrhosis.
• Women have higher wait-list mortality than men, due to
creatinine) underestimating severity of renal dysfunction &
women are shorter than men&smaller grafts are less available.
• Post-transplant graft & patient survival do not differ, with
exception of HCV: women have more severe recurrent
disease,with a 23% higher risk of advanced fibrosis after 3 years
• Women are also at higher risk of CKD post-transplant.

8. SEX DIFFERENCES :PHT comps
• Rates of complications are comparable in women & men.
• The development&progression of esophageal varices, portal
hypertensive gastropathy, ascites,spontaneous bacterial
peritonitis, encephalopathy are not affected by sex.
• GAVE/ portopulmonary hypertension, diagnosed more frequently
in women than men, reflect the higher prevalence of AI diseases.
• In cirrhosis, GAVE does not appear to a sex predilection.

9. SEX DIFFERENCES :HCC
• A lower risk of HCC in women than men due to protective effects
of estrogen.
• Higher testosterone level increase the risk.
• HCC diagnosed at an older age.
• Higher alpha-fetoprotein.
• More likely to have smaller unifocal & well-differentiated HCC
• A significantly longer survival than men after diagnosis ,may be
women were more compliant with surveillance.

10. SEX DIFFERENCES :Infertility
• A frequent anovulation or irregular ovulation, secondary to
hypothalamic-pituitary dysfunction& alteration in hepatic sex
hormone metabolism.
• Sexual dysfunction, as reduced sex frequency& satisfaction, was
more prevalent in women with endstage liver disease than in men.
• Increased age &more severe liver disease were related to lower
sexual frequency &satisfaction.

11. SEX DIFFERENCES :contraception
• Despite decreased fertility, undesired pregnancies can occur &
contraception must be discussed with premenopausal women.
• There was no restriction on the use of any hormonal
contraception &in women with severe, decompensated cirrhosis,
the risks usually outweigh the benefits.
• For IUD use caution is warranted, as SBP association reported.
• Barrier methods can be used, but failure rates are limiting.

12. SEX DIFFERENCES :Pregnancy
• The incidence of cirrhosis in pregnant women is very low, 1/ 6000
pregnancies.
• Pregnancies in women with cirrhosis carry higher risks for the
mother/ fetus ,so multidisciplinary team that includes a liver
specialist &high-risk obstetrician are essential throughout the
pregnancy & postpartum period.

13. SEX DIFFERENCES :Pregnancy
• Possible exacerbation of portal hypertension &its clinical
consequences as early as the sixth week& peak bet 30t-
34th week
gestation, due to normal physiologic changes of pregnancy.
• Significant maternal complication occurred in 10% of
pregnancies, included variceal bleeding, significant ascites& HE.
• For EV aggressive approach to prophylaxis is advised & for acute
variceal bleed during pregnancy, the endoscopic management is
similar to that in non-pregnant patients; EBL until obliteration.
• Octreo/vasopresin category B, decrease placental perfusion & an
increase risk of placental abruption.
• TIPS described during pregnancy, with negligible radiation
exposure with women survived&1 fetus died from premature
delivery, not considered TIPS-related.

14. SEX DIFFERENCES :Pregnancy
• Labor management is dependent on the degree of PHT.
• For women with known varices, caesarian delivery suggested, to
minimize the risk of variceal bleeding related to excessive
straining & ncreased intravariceal pressure with vaginal delivery.
• Very few cases of VH at the time of delivery reported & CS
delivery carries risks, including bleeding from injury to
abdominal wall collaterals, postoperative ascites, & poor wound-
healing issues&postop risk of worsening decompensation.
• Some experts suggest vaginal delivery by senior obstetrician,with
second stage of labor kept short / excessive fluid overload should
avoided& CS reserved for obstetric indications.
• For sedation, gentle intravenous labor analgesia can be given,&
epidural analgesia safety depends on the coagulopathy severity.
• Postpartum women with portal hypertension should also be
vigilantly watched for possible uterine hemorrhage.

15. SEX DIFFERENCES :Pregnancy
• Cirrhosis was associated with more risk of preeclampsia, preterm
delivery, low birth weight, small for gestational age&neonatal
death.

22. Macronodular cirrhosis

23. Micronodular cirrhosis