Chronic liver disease
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Transcript of Chronic liver disease
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Chronic liver disease
Multiple causes, common manifestation
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Cirrhosis A consequence of CLD Characterized by replacement of liver
tissue by fibrosis & regenerative nodules
Leads to irreversible loss of liver function & its complications
Micronodular- alcohol or Macronodular- chronic viral hepatitis
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Causes Alcoholic liver disease Chronic viral hepatitis- C or B Non-alcoholic steatohepatitis Autoimmune hepatitis PBC & PSC Hemochromatosis, Wilson’s disease α1-antitrypsin deficiency Cystic fibrosis
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Stigmata of CLD Muscle wasting Scratch marks Pallor, jaundice Parotid enlargement Xanthelasma Clubbing Palmar erythema Dupuytren’s contracture Spider nevi/angiomata
Petechiae, purpura Decreased body hair Gynecomastia Testicular atrophy Caput medusae Edema, ascites Splenomegaly Asterixis Fetor hepaticus
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Investigation Liver biopsy- gold standard, but not always
necessary Deranged LFT- ± elevated SGPT, alkaline phosphatase, GGT Increased bilirubin Low albumin, increased globulins Increased PT/INR Thrombocytopenia Low sodium Ultrasound- shrunken liver, ± portal HT/HCC EGD/UGIE- varices
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Staging of CLD Based on Child-Turcotte-Pugh scoring
system Includes- each given score of 1-3 Ascitis Encephalopathy Bilirubin Albumon PT/INR Class- total score A- 5-6 B- 7-9 C- 10-15
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Management
To retard progression & reduce complications
Abstinence from alcoholVaccination- Hep A & BTreat underlying cause
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Complications Ascites Spontaneous bacterial peritonitis- SBP Variceal bleed Hepatic encephalopathy Hepatorenal syndrome Hepatocellular carcinoma- HCC
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Ascitis
Diagnostic paracentesis- SAAG >1.1 Cause- Portal HT Hypoalbuminemia Raised renin-angiotensin-aldosterone levels
causing Na retention by kidneys
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Ascitis- treatment Salt ± fluid restriction Diuretics- Spironolactone ± Furosemide Large volume paracentesis- With massive or refractory ascitis >5 lit. fluid removed in one go Albumin- ~8 gm/lit. fluid removed Avoid hepatorenal syndrome TIPS- transjugular intrahepatic portosystemic shunt For refractory ascitis or refractory variceal bleed Preferred for short duration, pending liver transplant Increases risk of hepatic encephalopathy,
shunt occlusion/infection
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SBP s/s- Abdominal pain, fever, worsened
ascitis & encephalopathy Dx- paracentesis PMN >250/microlitre Ascitic fluid culture- bedside, commonly
Gram –ve bacteria Rx- Cefotaxime/Ciprofloxacin Prophylaxis- Ciprofloxacin/Co-trimoxazole Prognosis- 30% mortality during hospital stay
& 70% within 1 year
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Variceal bleed Varices- dilated submucosal veins, in
esophagus or stomach Cause- portal HT Causes ~80% of UGI bleed in CLD Risk factors for bleed- Size of varices Severity of liver disease Continued alcohol intake UGIE- wale markings, hematocystic/red spots on varix Dx- EGD/UGIE
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Management Acute- Resuscitation FFP, platelets, vit. K Terlipressin/octreotide Lactulose UGIE Banding/sclerotherapy Balloon tamponade TIPS Surgery
Prevent rebleed- Band ligation- over repeated
sessions Non-selective β- blockers-
Propanolol/Nadolol TIPS- for recurrent bleed or
bleed from gastric varices Surgery- portosystemic
shunts Liver transplantation
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Hepatic encephalopathy Confusiondrowsinessstuporcoma Ammonia is an identified/measurable toxin Precipitants- GI bleed Constipation Alkalosis, hypokalemia Sedatives Paracentesishypovolemia Infection TIPS Dx- clinical- s/s of CLD
with asterixis & altered sensorium
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Management Correct underlying precipitating factor Avoid sedatives Restrict dietary protein intake Lactulose- 2-3 loose stools a day Oral antibiotic- Metronidazole,
Rifaximin, Neomycin
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Hepatorenal syndrome Occurs in patients with advanced CLD &
ascitis Marked by renal impairment in the absence of
any renal parenchymal disease or shock Oliguria, hyponatremia & low urinary Na
accompany raised creatinine Albumin infusion, with vasoconstrictors
(norepinephrine, terlipressin/ornipressin, octreotide) may help
Liver transplantation is Rx of choice
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Hepatocellular carcinoma Associated with cirrhosis in ~80% Suspect if- worsening of CLD, enlarged liver,
hemorrhagic ascitis, weight loss Dx- CT/MRI with contrast- vascular SOL in cirrhotic liver Raised AFP- α-fetoprotein Liver biopsy Rx- Early-resection Advanced- liver transplantation or local palliative treatment Screening- US & AFP q 6 months
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Liver transplantation
Option in ESLDDonor, cost, technical expertise
GVHD, recurrence