Dr. Syifa M.-chronic Liver Disease Pit2014

Chronic Liver Disease: Complication and Treatment Syifa Mustika

A Patient Case… 54 year old gentleman presents to internist with increasing swelling of his abdomen and feet over the last 2 months. He has been increasing tired over this time and feels nauseous and is off his food. His wife has commented that his eyes have turned yellow over the last few days. He works in as a truck driver and smokes 10 cigarettes a day. He admits to drinking 2 cans of beer every weekend since young. His wife also says he sometimes drinks a bottle of whisky. On examination he is jaundiced but has no hepatic flap and is orientated in time, place and person. His abdomen is distended but soft and non-tender. There is no palpable organomegaly but there is shifting dullness. What are your main differential diagnoses for this gentleman?

Differential Diagnosis •

(Decompensated) Alcoholic liver disease

•

Viral liver disease

•

Hepatocellular Carcinoma

•

Pancreatic Cancer

•

Cryptogenic Liver Cirrhosis

•

Autoimmune liver disease

What further history would be needed? What signs would you look for on examination?

Signs of CLD

How would you investigate this patient? Bedside •

Observations, BM, fluid balance, weight

Blood tests •

LFTs (pre/post) (including albumin), INR

•

CBC, RFT, CRP

•

Liver screen: viral hepatitis serology, autoantibodies, alpha-1 antitrypsin

Imaging •

US abdomen + portal vein doppler

•

CXR, CT, MRI, MRCP

Special tests •

Ascitic tap, Endoscopic examination (oesophageal varices), liver biopsy

What is your management plan? Conservative • Alcohol abstinence, optimise nutrition, low salt diet, fluid restriction Medical • Vitamin B supplementation • Diuretics • Beta-blocker • Paracentesis (give albumin) • NG feeding • Antibiotics (? SBP) • Lactulose (in hepatic encephalopathy) Surgical • TIPS • Liver transplantation

What is possible complications and the prognosis of this patient? •

Portal hypertension: esophageal varices, ascites

•

SBP

•

Hepatic encephalopathy (constipation, GI bleed, infection, renal failure)

•

Hepatocellular carcinoma

•

Coagulopathy

•

Hepato-renal syndrome

•

Liver failure

Prognostic :

Calculates Child Pugh Score: bilirubin, INR, albumin, ascites, hepatic encephalopathy

Outline  Epidemiology

 Definition,

Etiologies and Classification  Clinical Presentation  Diagnostic Approach  Progostic Measurement  Management  Complications: Variceal Hemorrhage, HE, HRS

Epidemiology



Cirrhosis is the 12th leading cause of death in the United States.



It accounted for 29,165 deaths in 2007, with a mortality rate of 9.7 per 100,000 persons.



Cirrhosis is a major risk factor for the development of hepatocellular carcinoma; the incidence of this malignancy tripled from 1975 to 2005.

Definitions and Etiologies  The

word cirrhosis is derived from the Greek word kirrhos, meaning orange or tawny, and osis, meaning condition.

 World

Health Organization definition of cirrhosis is a diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules that lack normal lobular organization.

Classification Morphologic classification is less useful because of considerable overlap. 

Micronodular cirrhosis, with uniform nodules less than 3 mm in diameter: causes include alcohol, hemochromatosis, biliary obstruction, hepatic venous outflow obstruction, jejunoileal bypass, and Indian childhood cirrhosis.



Macronodular cirrhosis, with nodular variation greater than 3 mm in diameter: causes include chronic hepatitic C, chronic hepatitis B, alpha-1 antitrypsin deficiency, and primary biliary cirrhosis,



Mixed cirrhosis, a combination of micronodular and macronodular cirrhosis: micronodular cirrhosis frequently evolves into macronodular cirrhosis

Clinical Presentation

Diagnostic Approach

Prognostic Measurement

Management 

Management focuses on the treatment of complications



Surveillence for hepatocellular carcinoma with serial USG and serum alpha fetoprotein measurements at frequent intervals (e.g., every 6 months) Vaccination of cirrhotic patients against hepatitis A and B is recommended if patients lack serologic evidence of immunity.



Cirrhotic patients should be advised to avoid alcohol and other hepatotoxins.



In end-stage cirrhosis, liver transplantation can be a lifesaving procedure if the patient is an appropriate candidate

Complication  Ascites

 Variceal

Hemmorhage  Hepatic Encephalopathy  Hepatorenal Syndrome  Spontaneus Bacterial Peritonitis  Malnutrition  Hepatocellular Carcinoma

Variceal Hemorrhage •

ABC - Protect airway - High flow O2 - Haemodynamically stable?

- Bloods (Hb, Urea, Crossmatch 4-6 units), ABG - Fluid resuscitation – anything, blood is best

Correct clotting abnormalities (vitamin K, FFP) • Emergency endoscopy: banding, adrenaline injections • Somatostatin or Octreotide • IV omeprazole, antibiotics Rockall Risk Score: Age, Co-morbidities, Shock, Diagnosis, evidence of bleeding (OGD) •

Hepatic Encephalopathy • Reversible decrease in neurological function secondary to liver disease • Acute: seen with acute liver failure • Acute on chronic: established cirrhosis • Diagnosis :  Clinical (most important)  The drawing tests  EEG  CT/MRI may show cerebral atrophy

Hepatic Encephalopathy West Haven Criteria for Hepatic Encephalopathy •

Grade 1: shorted attention span, reversal of sleep-wake cycle, impaired performance of addiction or substraction (anxiety, irritability)

•

Grade 2: lethargy, subtle personality change, disorientation minimal of time and place. Asterixis.

•

Grade 3: stupor but responsive, severe confusion and disorientation, abnormal behaviour, incomprehensible speech, confusion and gross disorientation.

•

Grade 4: coma (unresponsive to verbal and stimuli)

Hepatic Encephalopathy - Treatment • • • • • • • •

Identify and treat precipitation factor Treat underlying liver disease Low to normal protein diet Antibiotics (Neomycin, metronidazole) Lactulose BCAA LOLA Liver Transplantation

Hepatorenal Syndrome • • • • • •

Progressive renal failure Type 1 : rapidly progressive, high mortality Type 2: slower progression R/O volume depletion secondary to diuretics IV vasoconstrictors Liver transplantation

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