Cirrhoses And Its Complications Ahmad Shavakhi.
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Transcript of Cirrhoses And Its Complications Ahmad Shavakhi.
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Cirrhoses And Its Complications
Ahmad Shavakhi
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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
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Ph.Exam• Gynecomastia• Minimal ascites• spelenomegaly• Palmar erythema• Spider angioma• Clubbing• Others were normal
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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
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Sonographic finding Sonographic finding
Small shrinkage liver Large spleen ascites
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EGD
• VARICIES :GRADE 1• Portal hypertensive gasteropathy
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What is your diagnosis ?What is your diagnosis ?
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• Is there any indication for liver Bx in this patient ?
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Liver biopsy is not necessary if the clinical, laboratory, and radiologic data strongly suggest the presence of cirrhosis
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What is the cause of cirrhosis ?
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Alcoholic liver disease Nash Hepatitis B and C Hemochromatosis AIH Wilson A1AT PBC and PSC
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LAB DATALAB DATA
• VIRAL MARKERS :NEG• AUTOIMMUNE MARKERS :NEG
• Alpha 1 antitrypsin :NL• Fe ,TIBC ,FERRITIN :NL
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LAB DATALAB DATA
• Ascites fluid :• SAAG :2.1• WBC :52 (60% LYMPHOCYTE,40%
PMN)• CULTURE :NEG
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What is the severity of cirrhosis ?
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MELD scoreMELD score
MELD = 3.8[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.6[Ln serum creatinine (mg/dL)] + 6.4
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CHILD-PUGH SCORING SYSTEM
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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
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• What is your dietary advice to this patient ?
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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
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Restrict• Milk(300ml)• Bread(two slices/day)
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omit• Anything containig baking powder
and baking soda(biscuits ,cakes)• Commercially prepared food• Tinned /bottled vegetables• Tinned meats/fish• Cheese
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Protein restriction ?
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What is the program of cancer screening in this patient?
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Screening for Screening for hepatocellular carcinomahepatocellular carcinoma
• periodic( every 6 months) ultrasound examination
• blood tests?
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After few months we found two mass in liver
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What is the next stepWhat is the next step
Biopsy MRI CT Observation
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Does the patient need for vaccination ?
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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
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Patient has headache ? Patient has headache ?
What is your advise as pain killer ?
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NSAID Acetaminophen Mixed drug COX2 inhibitors
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OpioidsOpioids
Morphine :twofold increase in the interval Meperidine :dose in patients with cirrhosis
should be decreased initially by 50 percent Tramadol and fentanyl :safe
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What is your idea about the exercise?
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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).
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Screen for encephalopathy
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When do you want to perform the next EGD for follow up?
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EVERY 2 Y
NO
VARICES
EVERY 1 Y
SMALL
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What does the patient do for
prevention of variceal bleeding ?
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Patient with small varices
(grade 1) : :
• Prophylaxis is not recommended
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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
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THE END THE END