8/14/2019 Cirrhosis Complications
1/32
CIRRHOSIS OF LIVERCIRRHOSIS OF LIVER
8/14/2019 Cirrhosis Complications
2/32
Cirrhosis is a condition in which the liverslowly deteriorates and malfunctions due tochronic injury. Scar tissue replaces healthyliver tissue, partially blocking the flow of
blood through the liver. Scarring alsoimpairs the livers ability tocontrol infections, remove bacteria andtoxins from the blood and process nutrients,
hormones, drugs andmake proteins that regulate blood clotting.Liver produces bile to help absorb fatsincluding cholesteroland fat-solublevitaminsA healthy liver is able to regenerate mostof its own cells when they become damaged.With end-stage cirrhosis, the liver can nolonger effectively replace damaged cells. A
healthy liver is necessary for survival.
8/14/2019 Cirrhosis Complications
3/32
VARICEAL HEMORRHAGEA type of varicose vein that develops inveins in the linings of the esophagus andupper stomach when these veins fill withblood as result of collateral circulationdue to portal hypertension. They get swollendue to an increase in blood pressure in theportal veins and tend to rupture. Bleeding
occurs in 1/3 patients with varices andtendency to bleed increases with largevarices, high pressure, more sever disease.Patients of variceal bleeding present withpainless but massive hematemesis with or
without melena. Proper history andexamination is required to exclude othercauses like peptic ulcer, portal hypertensivegastropathy and gastritis. In absence ofprevious history, the presence of
spleenomegaly, reduced liver span.
8/14/2019 Cirrhosis Complications
4/32
Investigations include: Blood CP(to measureinitial level of hemoglobin and platelate
count), PT & APTT, LFT, Serum electrolytes,Endoscopy(for detection of varices).Prophylactic measures include administrationof non-selective beta-blocker as propranololand the patients who cannot tolerate beta
blockers should be administered isosorbidemononitrate. Prophylactic sclerotherapy isnot indicated because of increased mortality.however binding in high risk individuals can
reduce the incidence
8/14/2019 Cirrhosis Complications
5/32
MANAGEMENT OF ACTIVEMANAGEMENT OF ACTIVE
BLEEDINGBLEEDING INITIAL RESUSCITATIONINITIAL RESUSCITATION monitor the blood pressure and pulsemonitor the blood pressure and pulse pass IV canula and give plasmapass IV canula and give plasmaexpander{gelafundin or haemaccel} to restoreexpander{gelafundin or haemaccel} to restorecirculation and arrange for blood and bloodcirculation and arrange for blood and bloodproducts such as fresh frozen plasmaproducts such as fresh frozen plasma
fresh frozen plasma is administered iffresh frozen plasma is administered ifpatents plasma PT is greater than 1.5 timespatents plasma PT is greater than 1.5 timesof normal.of normal.
Platelates should be infused if count isPlatelates should be infused if count is
less than 50,000 per microlitre.less than 50,000 per microlitre. Pass nasogastric tube to evacuate thePass nasogastric tube to evacuate thestomach to reduce nausea and vomiting and tostomach to reduce nausea and vomiting and tomonitor bleedingmonitor bleeding
8/14/2019 Cirrhosis Complications
6/32
URGENT ENDOSCOPYURGENT ENDOSCOPY
Urgent endoscopy is performed after theUrgent endoscopy is performed after thepatient has become hemodynamically stablepatient has become hemodynamically stable
that usually takes 2-12 hours. Endoscopicthat usually takes 2-12 hours. Endoscopic
examination is performed toexamination is performed to
exclude other causes of GI bleeding asexclude other causes of GI bleeding aspeptic ulcer and congestive gastropathy.peptic ulcer and congestive gastropathy.
For endoscopic treatment of varices withFor endoscopic treatment of varices with
either banding or sclerotherapyeither banding or sclerotherapy
8/14/2019 Cirrhosis Complications
7/32
BandingBanding Varices are sucked and rubber band isVarices are sucked and rubber band is
dislodged over the varicesdislodged over the varices Repeated banding sessions areRepeated banding sessions areperformed at interval of 1-2 weeksperformed at interval of 1-2 weeksuntil varices are oblitered.until varices are oblitered.
Banding varices lower the rate ofBanding varices lower the rate ofrebleeding and complications andrebleeding and complications anddeath than sclerotherapy, sodeath than sclerotherapy, so
therefore is treatment of choicetherefore is treatment of choice..
8/14/2019 Cirrhosis Complications
8/32
Injection sclerotherapy:
Varices are injected with sclerosingagent ethanolamine tetradecyl sulfatethat arrests bleeding by producingvessel thrombosis. A needle is passeddown the biopsy channel of endoscopeand sclerosing agent is injected intovarices, and repeatedly the session isperformed at interval of 3-7 days
followed by 1-3 weeks until varices areobliterated. Complications includechest pain, fever, bacteremia,espophageal ulceration, perforation and
stricture.
8/14/2019 Cirrhosis Complications
9/32
PHARMACOLOGICAL THERAPYPHARMACOLOGICAL THERAPY
Because of lack of facilities in our hospitalsBecause of lack of facilities in our hospitalsthe vasoconstrictor therapy is indicated tothe vasoconstrictor therapy is indicated toreduce the portal pressure. Octereotide isreduce the portal pressure. Octereotide istreatment of choice and vasopressin can alsotreatment of choice and vasopressin can also
be used. Octereotide reduces the splanchnicbe used. Octereotide reduces the splanchnicand hepatic blood flow and portal pressure inand hepatic blood flow and portal pressure incirrhosis patients and is comparable incirrhosis patients and is comparable inefficacy to sclerotherapy. It provides acuteefficacy to sclerotherapy. It provides acutecontrol of variceal bleeding. Vasopressin iscontrol of variceal bleeding. Vasopressin isnon selective vasoconstrictor and and reducesnon selective vasoconstrictor and and reduces
splanchnic blood flow but the complicationssplanchnic blood flow but the complicationsinclude angina, arrhythmia, and MI, so it isinclude angina, arrhythmia, and MI, so it iscontraindicated in patients with ischemiccontraindicated in patients with ischemicheart disease.heart disease.
8/14/2019 Cirrhosis Complications
10/32
OTHER MEASURES TO STOP BLEEDINGOTHER MEASURES TO STOP BLEEDING
Ballon temponadeBallon temponade Transjugular intrahepatic portocaval shuntTransjugular intrahepatic portocaval shunt
Lactulose and vitamin KLactulose and vitamin K
Emergency surgeryEmergency surgery
8/14/2019 Cirrhosis Complications
11/32
Ballon temponadeBallon temponade IT IS USED WHEN SCLEROTHERAPY HAS FAILED ORIT IS USED WHEN SCLEROTHERAPY HAS FAILED OR
UNAVAILABLE or vasoconstrictor therapy hasUNAVAILABLE or vasoconstrictor therapy has
failed or contraindicated. The sangstakenfailed or contraindicated. The sangstaken
blackmore tube is passed into stomach andblackmore tube is passed into stomach and
balloon is inflated with air and pulled backballoon is inflated with air and pulled back
which exerts pressure on lower esophagus andwhich exerts pressure on lower esophagus andgastric fundus to stop bleeding. Thegastric fundus to stop bleeding. The
complications include aspiration pneumonia,complications include aspiration pneumonia,
esophageal rupture and mucosal ulcerationesophageal rupture and mucosal ulceration..
8/14/2019 Cirrhosis Complications
12/32
Transjugular intrahepaticTransjugular intrahepatic
portocaval shuntportocaval shunt
Is performed when when pharmacologic andIs performed when when pharmacologic and
endoscopic therapies are failed. A guidedendoscopic therapies are failed. A guided
wire is passed from jugular vein intowire is passed from jugular vein into
liver and an expandable metal stent isliver and an expandable metal stent isforced over it into the liver mass to formforced over it into the liver mass to form
post systemic shunt between portal andpost systemic shunt between portal and
hepatic vein. Complication include stenthepatic vein. Complication include stent
stenosis or thrombosisstenosis or thrombosis..
8/14/2019 Cirrhosis Complications
13/32
Emergency surgeryEmergency surgery
PERFORMED WHEN OTHER MEASURES ARE FAILEDPERFORMED WHEN OTHER MEASURES ARE FAILED
or if tips is not available particularlyor if tips is not available particularly
if bleeding is from gastric fundalif bleeding is from gastric fundal
varices. The most common surgicalvarices. The most common surgicaltechnique is transaction of esophagus andtechnique is transaction of esophagus and
ligation of feeding vessel to bleedingligation of feeding vessel to bleeding
varices.varices.
8/14/2019 Cirrhosis Complications
14/32
lactulose and vitamin Klactulose and vitamin K Lactulose management is to preventLactulose management is to prevent
encephalopathy precipitated by large bleed.encephalopathy precipitated by large bleed.Vitamin K should be administered inVitamin K should be administered in
patients with prolonged PTpatients with prolonged PT
8/14/2019 Cirrhosis Complications
15/32
MEASURES TO STOP REBLEEDINGMEASURES TO STOP REBLEEDING
Repeated banding or scleropathy, betaRepeated banding or scleropathy, beta
blockers or nitrates and the shunts.blockers or nitrates and the shunts.
8/14/2019 Cirrhosis Complications
16/32
ASCITES
ASCITES ARE PATHOLOGICAL ACCUMMULATION OFFLUID IN PERITONEAL CAVITY. Ascitic fluidmay be exudate or transudate. Ascites arecommon complication of cirhosis of liver.Assessment of ascites
Grade 1 mild; Detectable only by USGrade 2 moderate; Moderate symmetricaldistension of the abdomen
Grade 3 large or gross asites with markedabdominal distension
8/14/2019 Cirrhosis Complications
17/32
Pathogenesis
oHypokalemia and Sodium and water retentiondue to stimulation of renin angiotensinsystem that develops as result of lowperfusion pressure of kidney in cirrhosis,
this retained fluid causes portalhypertension and ultimately the ascites.Nitric oxide is the vasodilator that causeslow perfusion pressure. Other agents areprostaglandins and natriuretic peptide.
oPortal hypertension that exerts localhydrostatic pressure causing transudation offluid in peritoneal cavity.
8/14/2019 Cirrhosis Complications
18/32
oLow serum albumin as result of poorsynthesis by liver causing reduced plasmaosmotic pressure and resulting in intransudation of fluids in peritoneal cavity
clinical features
abdominal distension wih fullness in flank
diffuse abdominal pain
features of the cause(commonly the chronicliver disease)
Dehydration
8/14/2019 Cirrhosis Complications
19/32
INVESTIGATION OF ASCITES
investigation of ascitic fluid
cirrhosis-----clear straw coloured orlight green
malignant disease-----bloody
infections-----cloudy
biliary communication-----heavy bilestating
lymnphatic obstruction-----milky white
8/14/2019 Cirrhosis Complications
20/32
cell count
neutrophil count is more than 250 per mm cube
albumin and total protein
SAAG is best is best single test toclassify the ascites according to their
cause by portal hypertenion and non-portalhypertension
SAAG more than 1.1 g/dl suggests thatunderlying portal hypertension and lessthan it suggests non-portal hypertension
SAAG
8/14/2019 Cirrhosis Complications
21/32
in 4% of patients High SAAG is due tomixed ascites(portal hypertension andmalignancy), so high SAAG indicated portal
hypertension but donot excludes malignancy
ascitic fluid protein level less than 1g/dl predispose the patient toward
spontaneous bacterial peritoniti
8/14/2019 Cirrhosis Complications
22/32
culture and gram stainperformed to identify infection of asciticfluidneutrophil count is more tha 250/mm cube
Other testRBC greater than 50000/micro litre denoteshemorrhaic ascites which is due tomalignancy, TB, and traumaGlucose is low in TB peritonitis
amylase is high in pancreatic ascites
8/14/2019 Cirrhosis Complications
23/32
ULTRASOUND ABDOMEN
confirms the presence of ascites
distinguishes between portal and non portal
cause of ascites.
shows the liver architecture and size ofportal vein
8/14/2019 Cirrhosis Complications
24/32
SPECIFIC MEASURES
DIURESIS
Spironolactone and furesimideL:spironolactone is diuretic of choice , itantagonizes aldosterone and prevents salt andwater reabsorption from kidney as secondary
hyperaldosteronism is major factor in saltand water retention in cirrhosis. Sideeffects are gynecomastia and hyperkalemia.Furesimide is high potency loop diuretic andshould be added to spironolactone if response
to spironolactone high doses is poor.
8/14/2019 Cirrhosis Complications
25/32
Therapeutic paracentesisin patients with massive ascites causingrespiratory distress or ascites refractory todiuretic therapy large volume paracentesisover 1-2 hours is effective. However there isrisk of hypovolumoa as ascitic fluidreaccumulates at expanse of circulating volume
leading to shock. This problem can be overcomeby administration of salt free albuminconcomitantly at dosage of 10g/l of asciticfluid removed to protect intravascular volume.
If the patient is non affording then useplasma expanders such as gelatin infusion125ml/l of ascitic fluid removed.
8/14/2019 Cirrhosis Complications
26/32
LeVeen Shunt and TIPSits a procedure in which a catheter isintroduced from peritoneal cavity intointernal jugular vein incorporating a one wayvalve and allowing the passage of asciticfluid directly into circulation. COMPLICATIONSARE superior vena caval thrombosis, pulmonary
edema, and bleeding from esophageal varices.TIPS is better than LeVeen shunt.
HEPATORENAL FAILURE
8/14/2019 Cirrhosis Complications
27/32
HEPATORENAL FAILURE
PATHOGENESIS
Hepatorenal syndrome is renal failure in absence of shock withend stage liver disease.
Occurs typically in patients with advanced cirrhosis with
jaundice and ascites. It presents as low urine output, raised urea
and creatinine. Low urinary sodium and hypotension.This is pre-renal type renal failure in which kidneys remain
histologically normal and if transplanted to non-cirrhotic patient
then they function normally.
Types of hepatorenal failure:
Type 1:doubling of serum creatinine to a level greater than
2.5mg/dl in less than 2 weeks
Type 2: is more slowly progressive and chronic
8/14/2019 Cirrhosis Complications
28/32
Hepatorenal syndrome develops due toreduced blood flow as result of lowperipheral resistance which leads toincreased secretion of vasoconstrictors
such as nor adrenaline, angiotensin,aldosterone and vasopressin that causevasoconstriction of renal vasculatureresulting in reduced GFR that leads to
extremely low sodium excretion andthere may be decreased production ofrenal vasodilators prostaglandinE2
PATHOGENESIS
8/14/2019 Cirrhosis Complications
29/32
PRECIPITATING FACTORS
Overvigrous diuretic therapy
DiarrheaGI bleedingSepsisLarge paracentesis
MANAGEMENT
The patient should be treated for pre renalfailure, the diuretic should be stopped and
intravascular hypovolemia is corrected withsalt free albumin. The dopamine infusion isineffective. TIPS may improve thecondition.
HEPATOPULMONARY SYNDROME
8/14/2019 Cirrhosis Complications
30/32
HEPATOPULMONARY SYNDROME
Hepatopulmonary syndrome occurs occurs
due to chronic liver disease and manifestas dyspnea in upright position(orthodeoxia) that is relieved byrecumbency.
PATHOGENESIS
Hypoxia and dyspnea develops due to right
to left intrapulmonary shunt because theliver is unable to clear the circulatorypulmonary vasodilators.
8/14/2019 Cirrhosis Complications
31/32
INVESTIGATION
Pulse oximetry shows oxygen saturation less
than 92%
Contrast echocardiography is sensitivescreening test for detecting intrapulmonary
shunts.
Macroaggregated albumin lung perfusionscanning is more specific and used to confirm
the diagnosis.
High resolution CT scan of chest showsdilated pulmonary vessels
8/14/2019 Cirrhosis Complications
32/32
MANAGEMENT
No specific treatment is available howeverIV methylene blue may improve oxygenation inpatients by inhibiting nitric oxide inducedvasodilation. TIPS may provide palliation in
patients awaiting liver transplantation.
Top Related