Cirrhoses And Its Complications

Ahmad Shavakhi

The patient• A 42 y/o man presented to clinic

complaining of malaise and weakness • He was well until 2 months ago when

weakness developed• Phx was unremarkable• On no medication

Ph.Exam• Gynecomastia• Minimal ascites• spelenomegaly• Palmar erythema• Spider angioma• Clubbing• Others were normal

LAB DATALAB DATA• AST =80• ALT =60• PT =15• PTT =52• Bil .D :2.1• Bil .T :3.2

• CBC :• WBC:5600• Hb :12

(MCV=84)• PLT :68000

• Na=125

Sonographic finding Sonographic finding

Small shrinkage liver Large spleen ascites

EGD

• VARICIES :GRADE 1• Portal hypertensive gasteropathy

What is your diagnosis ?What is your diagnosis ?

• Is there any indication for liver Bx in this patient ?

Liver biopsy is not necessary if the clinical, laboratory, and radiologic data strongly suggest the presence of cirrhosis

What is the cause of cirrhosis ?

Alcoholic liver disease Nash Hepatitis B and C Hemochromatosis AIH Wilson A1AT PBC and PSC

LAB DATALAB DATA

• VIRAL MARKERS :NEG• AUTOIMMUNE MARKERS :NEG

• Alpha 1 antitrypsin :NL• Fe ,TIBC ,FERRITIN :NL

LAB DATALAB DATA

• Ascites fluid :• SAAG :2.1• WBC :52 (60% LYMPHOCYTE,40%

PMN)• CULTURE :NEG

What is the severity of cirrhosis ?

MELD scoreMELD score

MELD = 3.8[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.6[Ln serum creatinine (mg/dL)] + 6.4

CHILD-PUGH SCORING SYSTEM

1 2 3

Ascites bil.T mg/dl

Alb g/l

PT*

INR

Encephalopathy    

Absent

<2

>3.5

<1.7

none

Slight

2-3

2.8-3.5

1.8-2.3 grade1-2

Moderate

>3

<2.8

>2.3

grade3-4

*: Second over control

1 2 3

• What is your dietary advice to this patient ?

Free use• Fresh and home-cooked fruit and

vegetables• Meat/poultry/fish(100g/day) and one

egg, one egg=50g meat• Unsalted butter,cooking oils,rice• Lemon juice,onion,garlic,pepper,• Fresh fruit juice• Salt free bread• Coffee,tea

Restrict• Milk(300ml)• Bread(two slices/day)

omit• Anything containig baking powder

and baking soda(biscuits ,cakes)• Commercially prepared food• Tinned /bottled vegetables• Tinned meats/fish• Cheese

Protein restriction ?

What is the program of cancer screening in this patient?

Screening for Screening for hepatocellular carcinomahepatocellular carcinoma

• periodic( every 6 months) ultrasound examination

• blood tests?

After few months we found two mass in liver

What is the next stepWhat is the next step

Biopsy MRI CT Observation

Does the patient need for vaccination ?

VaccinationVaccination

• Patients with cirrhosis are typically vaccinated against :• hepatitis A and B• Pneumococcal vaccine •  standard immunizations • Haemophilus influenzae and meningococcal :who require a

splenectomy • e suggest not routinely obtaining antibody titers after immunization.

Exceptions for hepatitis B vaccine• healthcare workers, • chronic hemodialysis• gay or bisexual men• spouses of carriers

Patient has headache ? Patient has headache ?

What is your advise as pain killer ?

NSAID Acetaminophen Mixed drug COX2 inhibitors

OpioidsOpioids

Morphine :twofold increase in the interval Meperidine :dose in patients with cirrhosis

should be decreased initially by 50 percent Tramadol and fentanyl :safe

What is your idea about the exercise?

Exercise

• generally safe for patients with cirrhosis that is not in an advanced stage.

• may increase the risk of variceal bleeding in advanced disease (such as those who have ascites or varices).

Screen for encephalopathy

When do you want to perform the next EGD for follow up?

EVERY 2 Y

NO

VARICES

EVERY 1 Y

SMALL

What does the patient do for

prevention of variceal bleeding ?

Patient with small varices

(grade 1) : :

• Prophylaxis is not recommended

Prophylaxis from variceal bleeding

Not Tolerate Not Tolerate

Medium &large varicesMedium &large varices

Band ligationBand ligation

No contraindication for Beta -blocker

No contraindication for Beta -blocker

ContraindicationFor Beta -blocker

ContraindicationFor Beta -blocker

TolerateTolerate

Start Beta blocker Start Beta blocker

THE END THE END