Download - Cirrhosis Of Liver
Cirrhosis of liverCirrhosis of liver
Dr Aye Myint KhineDr Aye Myint Khine
At any ageAt any age Prolonged morbidityProlonged morbidity Younger adultsYounger adults Premature deathPremature death
AetiologyAetiology
Any causes of chronic hepatitisAny causes of chronic hepatitis
AlcoholAlcohol
PBCPBC
PSCPSC
Secondary biliary cirrhosisSecondary biliary cirrhosis
HaemochromatosisHaemochromatosis
Wilson’s diseaseWilson’s disease
Alpha 1 antitrypsin deficiencyAlpha 1 antitrypsin deficiency
Cystic fibrosisCystic fibrosis
Histological typeHistological type
Micronodular cirrhosis –small nodules Micronodular cirrhosis –small nodules about 1mmabout 1mm
Macronodular cirrhosis-larger nodulesMacronodular cirrhosis-larger nodules
Clinical featuresClinical features
AsymptomaticAsymptomatic
mild hepatomegalymild hepatomegaly
Non-specific GI symptomsNon-specific GI symptoms
JaundiceJaundice
Mild haemolysisMild haemolysis
Circulatory changesCirculatory changes
Endocrine changesEndocrine changes
Clinical features continuedClinical features continued
Haemorrhagic tendencyHaemorrhagic tendency
Portal hypertensionPortal hypertension
Hepatic encephalopathyHepatic encephalopathy
Non-specific featuresNon-specific features
ComplicationsComplications
Portal hypertensionPortal hypertension Ascites Ascites Hepatic encephalopathyHepatic encephalopathy Spontaneous bacterial peritonitisSpontaneous bacterial peritonitis Renal failureRenal failure InfectionInfection Hepatocellular carcinomaHepatocellular carcinoma
AscitesAscites
Accumulation of free fluid in the peritoneal cavityAccumulation of free fluid in the peritoneal cavity Underfilling theoryUnderfilling theory Overflow theoryOverflow theory Activation of Na and water Activation of Na and water
RAARAAincreased sympathetic nervous activityincreased sympathetic nervous activityalteration of ADH secretionalteration of ADH secretionaltered activity of th kallikrein - kinin systemaltered activity of th kallikrein - kinin system
Hepatic encephalopathyHepatic encephalopathy
Neuropsychiatric syndrome caused by liver diseaseNeuropsychiatric syndrome caused by liver disease Precipitating factorsPrecipitating factors Changes in interllet,personality,emotions & conciousnessChanges in interllet,personality,emotions & conciousness Apathy Apathy Impaired concentration,confusion,convulsion& Impaired concentration,confusion,convulsion&
drowsinessdrowsiness Flapping tremorFlapping tremor
Hepatic encephalopathyHepatic encephalopathy
Constructional apraxiaConstructional apraxia Hyperreflexia & bilat ext planter responseHyperreflexia & bilat ext planter response Fetor hepaticusFetor hepaticus Cerebellar signs,parkinsonian syndromes,spastic Cerebellar signs,parkinsonian syndromes,spastic
paraparesisparaparesis dementiadementia
GradingGrading
Clinical gradingClinical grading Clinical signsClinical signs Grade1Grade1 poor concentration,slurred speech,slow poor concentration,slurred speech,slow
mentation,disordered sleep mentation,disordered sleep patternpattern
Grade 2Grade 2 drowsy but easily rousable,occasional drowsy but easily rousable,occasional aggressive behaviour,lethergicaggressive behaviour,lethergic
Grade 3Grade 3 marked confusion,drowsy,sleepy,but marked confusion,drowsy,sleepy,but
responds to pain and voice,gross responds to pain and voice,gross disorientationdisorientation
Grade 4Grade 4 unresponse to voice,may or may not unresponse to voice,may or may not respond to painful stimulirespond to painful stimuli
Spontaneous peritonitisSpontaneous peritonitis
Abdominal painAbdominal pain Rebound tendernessRebound tenderness Absent bowel soundsAbsent bowel sounds FeverFever Ascites neutrophil count >250mmAscites neutrophil count >250mm33
E .coliE .coli
Renal failureRenal failure
Kidneys normalKidneys normal Result from altered systemic blood flowResult from altered systemic blood flow Functional renal failure /hepatorenal syndromeFunctional renal failure /hepatorenal syndrome Absence if proteinuria/abnormal urinaryAbsence if proteinuria/abnormal urinary
sedimentsedimentUrine Na <10 mmol/dUrine Na <10 mmol/dUrine/plasma osmolarlity >1.5Urine/plasma osmolarlity >1.5
InvestigationsInvestigations
Blood for CPBlood for CP LFT,AST,ALT,GGTLFT,AST,ALT,GGT T&DPT&DP OSPTOSPT UreaUrea GlucoseGlucose Ultrasound abdomenUltrasound abdomen CXRCXR EEGEEG
ManagementManagement
General managementGeneral management
Specific treatmentsSpecific treatments
Treatment of complications of cirrhosisTreatment of complications of cirrhosis
Orthotopic liver transplantationOrthotopic liver transplantation
General managementGeneral management
Good nutritionGood nutrition
Avoid protein excessAvoid protein excess
Low salt dietLow salt diet
Alcohol absteinenceAlcohol absteinence
Avoid NSAID and sedatives & opiatesAvoid NSAID and sedatives & opiates
Cholestyramine for pruritusCholestyramine for pruritus
Specific treatmentsSpecific treatments
Alpha interferon with ribavirin improve liver biochemistry Alpha interferon with ribavirin improve liver biochemistry
& may retard development of HCC in HCV induced & may retard development of HCC in HCV induced
cirrhosiscirrhosis
Little benefit of UDCA in PBCLittle benefit of UDCA in PBC
Penicillinmine for Wilson’s diseasePenicillinmine for Wilson’s disease
Venesection for haemochromatosisVenesection for haemochromatosis
Management of complicationsManagement of complications
AscitesAscites
low salt dietlow salt diet 40mmol/d -20mmmol/d40mmol/d -20mmmol/d
avoid NSAID avoid NSAID
fluid restrictionfluid restriction 0.5-1 l/24 hr 0.5-1 l/24 hr
-spironolactone 100mg/24 hr orally-spironolactone 100mg/24 hr orally
increase dose every 48 hr to 400mg/24hrincrease dose every 48 hr to 400mg/24hr
daily weight chart weight loss <1/2 kg/daydaily weight chart weight loss <1/2 kg/day
-frusemide 160mg/d-frusemide 160mg/d
-therapeutic paracentesis+ commitant albumin infusion-therapeutic paracentesis+ commitant albumin infusion
(6-8l fluid removed) (6-8l fluid removed)
Management of complications continuedManagement of complications continued
Spontaneous bacterial peritonitisSpontaneous bacterial peritonitis
-I.V cefuroxine1.5 g 8hrly +-I.V cefuroxine1.5 g 8hrly +
metronidazole 500mg 8hrlymetronidazole 500mg 8hrly
-Prophylaxis ; ciprofloxacin 250mg orally-Prophylaxis ; ciprofloxacin 250mg orally
cotrimoxazole 960mg weekdays onlycotrimoxazole 960mg weekdays only
Management of complications continuedManagement of complications continued
Hepatic encephalopathyHepatic encephalopathy
Reduce protein intakeReduce protein intake
High calorie dietHigh calorie diet
Lactulose 15-30ml tdsLactulose 15-30ml tds
Neomycin 1-4 g 4-6hrlyNeomycin 1-4 g 4-6hrly
Hepatorenal syndromeHepatorenal syndrome
18% of cirrhosis patients18% of cirrhosis patients
IV albumin with/without haemodialysisIV albumin with/without haemodialysis
Indications for liver transplantationIndications for liver transplantation
cholestatic forms of cirrhosischolestatic forms of cirrhosis
PBC PBC
Alcoholic cirrhosisAlcoholic cirrhosis
cirrhosis due to hepatitis Ccirrhosis due to hepatitis C
Alpha1Antitrypsin deficiency Alpha1Antitrypsin deficiency
HaemochromatosisHaemochromatosis
Signs of liver insuffiency pointing to the need for Signs of liver insuffiency pointing to the need for liver transplantliver transplant
Sustained or increased jaundiceSustained or increased jaundice TB >100 Umol/lTB >100 Umol/l Ascites Ascites Hepatic encephalopathy not responding to medical Hepatic encephalopathy not responding to medical
therapytherapy hypoalbuminaemia <30g/lhypoalbuminaemia <30g/l Fatigue and lethargy affecting the quality of lifeFatigue and lethargy affecting the quality of life Intractable itichingIntractable itiching Recurrent variceal bleedingRecurrent variceal bleeding
Contraindications Contraindications
SepsisSepsis
AIDSAIDS
Extrahepatic malignancyExtrahepatic malignancy
Active alcohol and other substance abuseActive alcohol and other substance abuse
Marked cardiorespiratory dysfunctionMarked cardiorespiratory dysfunction
PrognosisPrognosis
Overall prognosis is poorOverall prognosis is poor
25% survive 5 years from diagnosis25% survive 5 years from diagnosis
If liver function is good,If liver function is good,
50% survive for 5 years50% survive for 5 years
25% upto 10 years25% upto 10 years
Poor prognostic factorsPoor prognostic factors
Deteriorating liver functionDeteriorating liver function
Falling albuminFalling albumin
Serum albumin <30g/lSerum albumin <30g/l
Marked hyponatremia<120mg%Marked hyponatremia<120mg%
Prolonged PTProlonged PT
Portal hypertensionPortal hypertension
Prolonged elevation of portal venous pressure( normal 2-Prolonged elevation of portal venous pressure( normal 2-5mmHg)5mmHg)
>12mmHg>12mmHg
CausesCauses
Extrahepatic post sinusoidalExtrahepatic post sinusoidal
Budd-Chiai syndromeBudd-Chiai syndrome
Intrahepatic post sinusoidalIntrahepatic post sinusoidal
Venoocclusive diseaseVenoocclusive disease
SinusoidalSinusoidal
CirrhosisCirrhosis
Cystic liver diseaseCystic liver disease
Partial nodular transformation of liverPartial nodular transformation of liver
Metastatic malignant diseaseMetastatic malignant disease
Causes continuedCauses continued
Intrahepatic pre-sinusoidalIntrahepatic pre-sinusoidal
SchistosomiasisSchistosomiasis
sarcoidosissarcoidosis
congenital hepatic fibrosiscongenital hepatic fibrosis
Vinyl chlorideVinyl chloride
DrugsDrugs Extrahepatic pre-sinusoidalExtrahepatic pre-sinusoidal
Portal vein thrombosisPortal vein thrombosis
Abdominal traumaAbdominal trauma
Malignant diseaseof pancreas and liverMalignant diseaseof pancreas and liver
pancreatitispancreatitis
congenitalcongenital
Clinical featuresClinical features
Portal venous congestionPortal venous congestion Collateral formationCollateral formation SplenomegalySplenomegaly HypersplenismHypersplenism
thrombocytopenia 100x 10thrombocytopenia 100x 1099/l/l
leucopenia leucopenia
AnaemiaAnaemia
Collateral vessels on ant abd wall around umblicusCollateral vessels on ant abd wall around umblicus
Oesophageal varicesOesophageal varices
Rectal varicesRectal varices
Fetal hepaticusFetal hepaticus
InvestigationsInvestigations
Barium swallow x rayBarium swallow x ray
USS abdomen USS abdomen
splenomegaly splenomegaly
liver disease liver disease
portal vein thrombosisportal vein thrombosis
Endoscopy collateral vesselsEndoscopy collateral vessels
Portal venographyPortal venography
ComplicationsComplications
Variceal bleeding (oesophageal,gastric,other (rare)Variceal bleeding (oesophageal,gastric,other (rare)
Congestive gastropathyCongestive gastropathy
HypersplenismHypersplenism
AscitesAscites
Renal failureRenal failure
Hepatic encephalopathyHepatic encephalopathy
Variceal bleedingVariceal bleeding
Oesophageal bleeding within 3-5 cm fr oesophagogastric Oesophageal bleeding within 3-5 cm fr oesophagogastric
junctionjunction
gastric varicesgastric varices
Size of varicesSize of varices
High portal prHigh portal pr
Liver failureLiver failure
DrugsDrugs
Management of acute variceal bleedingManagement of acute variceal bleeding
To restore circulationTo restore circulation Reduction of portal pressureReduction of portal pressure Local measuresLocal measures
Reduction of portal pressureReduction of portal pressure
Less important >sclerotherapy or bandingLess important >sclerotherapy or banding Pharmacological measuresPharmacological measures
vasopressin I/Vvasopressin I/V 0.4 U/min x 24 hrs0.4 U/min x 24 hrs
0.2 U/min x 24 hrs0.2 U/min x 24 hrs
TerlipressionTerlipression 2mg iv 6hrly 2mg iv 6hrly
1mg iv 6hrly x 24 hrs1mg iv 6hrly x 24 hrs
OtreotideOtreotide 50ug iv stat & hrly infusion50ug iv stat & hrly infusion
TIPSS & shunt surgery TIPSS & shunt surgery
-high mortality-high mortality
Local measuresLocal measures
Sclerotherapy or bandingSclerotherapy or banding
daignostic endoscopydaignostic endoscopy
stop bleeding in 80% of patientsstop bleeding in 80% of patients
can be repeated if bleeding recurscan be repeated if bleeding recurs Balloon tamponadeBalloon tamponade
Sengstaken-BlakemoreSengstaken-Blakemore
Minnesota tubeMinnesota tube
Oesophageal transectionOesophageal transection
stapling gun stapling gun
spleenectomyspleenectomy
Prevention of recurrent bleedingPrevention of recurrent bleeding
SclerotherapySclerotherapy
sclerosing agentssclerosing agents
1-2 weekly1-2 weekly
S/E feverS/E fever
Transient chest pain/abdoTransient chest pain/abdo
Transient dysphagia Transient dysphagia
oesophageal perforationoesophageal perforation
Low mortalityLow mortality
Prevention of recurrent bleedingPrevention of recurrent bleeding
BandingBanding
occluded with tight rubber bandoccluded with tight rubber band
More effective More effective
Fewer S/E Fewer S/E
Prevention of recurrent bleedingPrevention of recurrent bleeding
TIPSSTIPSS
Stent placed b/t portal vein &hepatic vein in the liverStent placed b/t portal vein &hepatic vein in the liver
under radiological contol under radiological contol
t/h Internal jugular veint/h Internal jugular vein
Prior angiographyPrior angiography
FFPFFP
Antibiotic coverAntibiotic cover
S/ES/E Shunt narrowing/occlusionShunt narrowing/occlusion
Hepatic encephalopathyHepatic encephalopathy
Portasystemic shunt surgeryPortasystemic shunt surgery
High mortalityHigh mortality
Non-selective shuntNon-selective shunt
Postop liver failurePostop liver failure
Hepatic encephalopathyHepatic encephalopathy
More selective shuntMore selective shunt
less post hepatic encephalopathyless post hepatic encephalopathy
Preserved for patients in whom other treatments have Preserved for patients in whom other treatments have
not been successfulnot been successful
PropranololPropranolol
80-160mg/day,80-160mg/day,
Not widely used:Poor complianceNot widely used:Poor compliance
use for primary preventionuse for primary prevention
Child-pugh grading and risk of variceal bleedingChild-pugh grading and risk of variceal bleeding
pointspoints 1 1 22 33
Bilirubin(Bilirubin(µmol/l)µmol/l) <34<34 34-5134-51 >51>51
Albumin(g/l)Albumin(g/l) >3.5>3.5 2.8-3.52.8-3.5 <2.8<2.8
PT(seconds>normal)PT(seconds>normal) 1-31-3 4-64-6 >6>6
AscitesAscites NoneNone slightslight moderatemoderate
EncephalopathyEncephalopathy NoneNone 1-21-2 3-43-4
Points ≥ 8 Points ≥ 8 risk risk
Congestive gastropathyCongestive gastropathy
EndoscopyEndoscopy
multiple areas of punctate erythemamultiple areas of punctate erythema
distally GITdistally GIT
erosion –bleedingerosion –bleeding
IDAIDA
TreatmentTreatment
propranololpropranolol
TIPSSTIPSS
MCQ MCQ
1.Clinical features of cirrhosis of the liver includes1.Clinical features of cirrhosis of the liver includes
(a)(a) HepatomegalyHepatomegaly
(b)(b) JaundiceJaundice
(c)(c) Palmer erythemaPalmer erythema
(d)(d) AmenorrhoeaAmenorrhoea
(e)(e) Low grade feverLow grade fever
MCQMCQ
2.Complications of cirrhosis are2.Complications of cirrhosis are
(a)(a) Portal hypertensionPortal hypertension
(b)(b) Ascites Ascites
(c)(c) Hepatic encephalopathyHepatic encephalopathy
(d)(d) Renal failureRenal failure
(e)(e) BacteraemiaBacteraemia
MCQMCQ
3.Poor prognostic factors includes3.Poor prognostic factors includes
(a)(a) HypoalbuminaemiaHypoalbuminaemia
(b)(b) HypernatraemiaHypernatraemia
(c)(c) Increasing total bilirubinIncreasing total bilirubin
(d)(d) Prolonged prothrombin timeProlonged prothrombin time
(e)(e) Cirrhosis due to haemochromatosisCirrhosis due to haemochromatosis
MSQMSQ
What are the common causes of cirrhosisWhat are the common causes of cirrhosis
of liver? How would you manage a case of of liver? How would you manage a case of
COL with hepatic encephalopathy?COL with hepatic encephalopathy?
MCQMCQ
1.Clinical features of portal hypertension are1.Clinical features of portal hypertension are
(a)(a) SplenomegalySplenomegaly
(b)(b) HypersplenismHypersplenism
(c)(c) JaundiceJaundice
(d)(d) Fetor hepaticusFetor hepaticus
(e)(e) Spider naeviSpider naevi
MCQMCQ
2. Following drugs can be used in acute 2. Following drugs can be used in acute variceal bleedingvariceal bleeding
(a)(a) VasopressinVasopressin
(b)(b) NSAIDNSAID
(c)(c) TerlipressinTerlipressin
(d)(d) Octreotide Octreotide
(e)(e) Beta blocker Beta blocker
MSQMSQ
Describe management of acute GI Describe management of acute GI bleeding due to rupture oesophageal bleeding due to rupture oesophageal varices.What preventive measures would varices.What preventive measures would you give to prevent recurrent bleeding?you give to prevent recurrent bleeding?