dr. syifa m.-chronic liver disease pit2014
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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?
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
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)
• 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
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)
• Identify and treat precipitation factor
• Treat underlying liver disease
• Low to normal protein diet
• Antibiotics (Neomycin, metronidazole)
• Lactulose
• BCAA
• LOLA
• Liver Transplantation
Hepatic Encephalopathy - Treatment
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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