Cirrhosis Of Liver

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Cirrhosis Of Liver

  1. 1. Cirrhosis of liver Dr Aye Myint Khine
  2. 2. <ul><li>At any age </li></ul><ul><li>Prolonged morbidity </li></ul><ul><li>Younger adults </li></ul><ul><li>Premature death </li></ul>
  3. 3. Aetiology <ul><li>Any causes of chronic hepatitis </li></ul><ul><li>Alcohol </li></ul><ul><li>PBC </li></ul><ul><li>PSC </li></ul><ul><li>Secondary biliary cirrhosis </li></ul><ul><li>Haemochromatosis </li></ul><ul><li>Wilson’s disease </li></ul><ul><li>Alpha 1 antitrypsin deficiency </li></ul><ul><li>Cystic fibrosis </li></ul>
  4. 4. Histological type <ul><li>Micronodular cirrhosis –small nodules about 1mm </li></ul><ul><li>Macronodular cirrhosis-larger nodules </li></ul>
  5. 5. Clinical features <ul><li>Asymptomatic </li></ul><ul><li>mild hepatomegaly </li></ul><ul><li>Non-specific GI symptoms </li></ul><ul><li>Jaundice </li></ul><ul><li>Mild haemolysis </li></ul><ul><li>Circulatory changes </li></ul><ul><li>Endocrine changes </li></ul>
  6. 6. Clinical features continued <ul><li>Haemorrhagic tendency </li></ul><ul><li>Portal hypertension </li></ul><ul><li>Hepatic encephalopathy </li></ul><ul><li>Non-specific features </li></ul>
  7. 7. Complications <ul><li>Portal hypertension </li></ul><ul><li>Ascites </li></ul><ul><li>Hepatic encephalopathy </li></ul><ul><li>Spontaneous bacterial peritonitis </li></ul><ul><li>Renal failure </li></ul><ul><li>Infection </li></ul><ul><li>Hepatocellular carcinoma </li></ul>
  8. 8. Ascites <ul><li>Accumulation of free fluid in the peritoneal cavity </li></ul><ul><li>Underfilling theory </li></ul><ul><li>Overflow theory </li></ul><ul><li>Activation of Na and water </li></ul><ul><li>RAA </li></ul><ul><li>increased sympathetic nervous activity </li></ul><ul><li>alteration of ADH secretion </li></ul><ul><li>altered activity of th kallikrein - kinin system </li></ul>
  9. 9. Hepatic encephalopathy <ul><li>Neuropsychiatric syndrome caused by liver disease </li></ul><ul><li>Precipitating factors </li></ul><ul><li>Changes in interllet,personality,emotions & conciousness </li></ul><ul><li>Apathy </li></ul><ul><li>Impaired concentration,confusion,convulsion& drowsiness </li></ul><ul><li>Flapping tremor </li></ul>
  10. 10. Hepatic encephalopathy <ul><li>Constructional apraxia </li></ul><ul><li>Hyperreflexia & bilat ext planter response </li></ul><ul><li>Fetor hepaticus </li></ul><ul><li>Cerebellar signs,parkinsonian syndromes,spastic paraparesis </li></ul><ul><li>dementia </li></ul>
  11. 11. Grading <ul><li>Clinical grading Clinical signs </li></ul><ul><li>Grade1 poor concentration,slurred speech,slow mentation,disordered sleep pattern </li></ul><ul><li>Grade 2 drowsy but easily rousable,occasional aggressive behaviour,lethergic </li></ul><ul><li>Grade 3 marked confusion,drowsy,sleepy,but </li></ul><ul><li>responds to pain and voice,gross disorientation </li></ul><ul><li>Grade 4 unresponse to voice,may or may not respond to painful stimuli </li></ul>
  12. 12. Spontaneous peritonitis <ul><li>Abdominal pain </li></ul><ul><li>Rebound tenderness </li></ul><ul><li>Absent bowel sounds </li></ul><ul><li>Fever </li></ul><ul><li>Ascites neutrophil count >250mm 3 </li></ul><ul><li>E .coli </li></ul>
  13. 13. Renal failure <ul><li>Kidneys normal </li></ul><ul><li>Result from altered systemic blood flow </li></ul><ul><li>Functional renal failure /hepatorenal syndrome </li></ul><ul><li>Absence if proteinuria/abnormal urinary </li></ul><ul><li> sediment </li></ul><ul><li>Urine Na <10 mmol/d </li></ul><ul><li>Urine/plasma osmolarlity >1.5 </li></ul>
  14. 14. Investigations <ul><li>Blood for CP </li></ul><ul><li>LFT,AST,ALT,GGT </li></ul><ul><li>T&DP </li></ul><ul><li>OSPT </li></ul><ul><li>Urea </li></ul><ul><li>Glucose </li></ul><ul><li>Ultrasound abdomen </li></ul><ul><li>CXR </li></ul><ul><li>EEG </li></ul>
  15. 15. Management <ul><li>General management </li></ul><ul><li>Specific treatments </li></ul><ul><li>Treatment of complications of cirrhosis </li></ul><ul><li>Orthotopic liver transplantation </li></ul>
  16. 16. General management <ul><li>Good nutrition </li></ul><ul><li>Avoid protein excess </li></ul><ul><li>Low salt diet </li></ul><ul><li>Alcohol absteinence </li></ul><ul><li>Avoid NSAID and sedatives & opiates </li></ul><ul><li>Cholestyramine for pruritus </li></ul>
  17. 17. Specific treatments <ul><li>Alpha interferon with ribavirin improve liver biochemistry & may retard development of HCC in HCV induced cirrhosis </li></ul><ul><li>Little benefit of UDCA in PBC </li></ul><ul><li>Penicillinmine for Wilson’s disease </li></ul><ul><li>Venesection for haemochromatosis </li></ul>
  18. 18. Management of complications <ul><li>Ascites </li></ul><ul><li>low salt diet 40mmol/d -20mmmol/d </li></ul><ul><li>avoid NSAID </li></ul><ul><li>fluid restriction 0.5-1 l/24 hr </li></ul><ul><li>-spironolactone 100mg/24 hr orally </li></ul><ul><li>increase dose every 48 hr to 400mg/24hr </li></ul><ul><li>daily weight chart weight loss <1/2 kg/day </li></ul><ul><li>-frusemide 160mg/d </li></ul><ul><li>-therapeutic paracentesis+ commitant albumin infusion </li></ul><ul><li>(6-8l fluid removed) </li></ul>
  19. 19. Management of complications continued <ul><li>Spontaneous bacterial peritonitis </li></ul><ul><li>-I.V cefuroxine1.5 g 8hrly + </li></ul><ul><li>metronidazole 500mg 8hrly </li></ul><ul><li>-Prophylaxis ; ciprofloxacin 250mg orally </li></ul><ul><li> cotrimoxazole 960mg weekdays only </li></ul>
  20. 20. Management of complications continued <ul><li>Hepatic encephalopathy </li></ul><ul><li>Reduce protein intake </li></ul><ul><li>High calorie diet </li></ul><ul><li>Lactulose 15-30ml tds </li></ul><ul><li>Neomycin 1-4 g 4-6hrly </li></ul><ul><li>Hepatorenal syndrome </li></ul><ul><li>18% of cirrhosis patients </li></ul><ul><li>IV albumin with/without haemodialysis </li></ul>
  21. 21. Indications for liver transplantation <ul><li>cholestatic forms of cirrhosis </li></ul><ul><li>PBC </li></ul><ul><li>Alcoholic cirrhosis </li></ul><ul><li>cirrhosis due to hepatitis C </li></ul><ul><li>Alpha1Antitrypsin deficiency </li></ul><ul><li>Haemochromatosis </li></ul>
  22. 22. Signs of liver insuffiency pointing to the need for liver transplant <ul><li>Sustained or increased jaundice </li></ul><ul><li>TB >100 Umol/l </li></ul><ul><li>Ascites </li></ul><ul><li>Hepatic encephalopathy not responding to medical therapy </li></ul><ul><li>hypoalbuminaemia <30g/l </li></ul><ul><li>Fatigue and lethargy affecting the quality of life </li></ul><ul><li>Intractable itiching </li></ul><ul><li>Recurrent variceal bleeding </li></ul>
  23. 23. Contraindications <ul><li>Sepsis </li></ul><ul><li>AIDS </li></ul><ul><li>Extrahepatic malignancy </li></ul><ul><li>Active alcohol and other substance abuse </li></ul><ul><li>Marked cardiorespiratory dysfunction </li></ul>
  24. 24. Prognosis <ul><li>Overall prognosis is poor </li></ul><ul><li>25% survive 5 years from diagnosis </li></ul><ul><li>If liver function is good, </li></ul><ul><li>50% survive for 5 years </li></ul><ul><li>25% upto 10 years </li></ul>
  25. 25. Poor prognostic factors <ul><li>Deteriorating liver function </li></ul><ul><li>Falling albumin </li></ul><ul><li>Serum albumin <30g/l </li></ul><ul><li>Marked hyponatremia<120mg% </li></ul><ul><li>Prolonged PT </li></ul>
  26. 26. Portal hypertension <ul><li>Prolonged elevation of portal venous pressure( normal 2-5mmHg) </li></ul><ul><li>>12mmHg </li></ul>
  27. 27. Causes <ul><li>Extrahepatic post sinusoidal </li></ul><ul><li>Budd-Chiai syndrome </li></ul><ul><li>Intrahepatic post sinusoidal </li></ul><ul><li>Venoocclusive disease </li></ul><ul><li>Sinusoidal </li></ul><ul><li>Cirrhosis </li></ul><ul><li>Cystic liver disease </li></ul><ul><li>Partial nodular transformation of liver </li></ul><ul><li>Metastatic malignant disease </li></ul>
  28. 28. Causes continued <ul><li>Intrahepatic pre-sinusoidal </li></ul><ul><li>Schistosomiasis </li></ul><ul><li>sarcoidosis </li></ul><ul><li>congenital hepatic fibrosis </li></ul><ul><li>Vinyl chloride </li></ul><ul><li>Drugs </li></ul><ul><li>Extrahepatic pre-sinusoidal </li></ul><ul><li>Portal vein thrombosis </li></ul><ul><li>Abdominal trauma </li></ul><ul><li>Malignant diseaseof pancreas and liver </li></ul><ul><li>pancreatitis </li></ul><ul><li>congenital </li></ul>
  29. 29. Clinical features <ul><li>Portal venous congestion </li></ul><ul><li>Collateral formation </li></ul><ul><li>Splenomegaly </li></ul><ul><li>Hypersplenism </li></ul><ul><li>thrombocytopenia 100x 10 9 /l </li></ul><ul><li>leucopenia </li></ul><ul><li>Anaemia </li></ul><ul><li>Collateral vessels on ant abd wall around umblicus </li></ul><ul><li>Oesophageal varices </li></ul><ul><li>Rectal varices </li></ul><ul><li>Fetal hepaticus </li></ul>
  30. 30. Investigations <ul><li>Barium swallow x ray </li></ul><ul><li>USS abdomen </li></ul><ul><li>splenomegaly </li></ul><ul><li>liver disease </li></ul><ul><li>portal vein thrombosis </li></ul><ul><li>Endoscopy collateral vessels </li></ul><ul><li>Portal venography </li></ul>
  31. 31. Complications <ul><li>Variceal bleeding (oesophageal,gastric,other (rare) </li></ul><ul><li>Congestive gastropathy </li></ul><ul><li>Hypersplenism </li></ul><ul><li>Ascites </li></ul><ul><li>Renal failure </li></ul><ul><li>Hepatic encephalopathy </li></ul>
  32. 32. Variceal bleeding <ul><li>Oesophageal bleeding within 3-5 cm fr oesophagogastric junction </li></ul><ul><li>gastric varices </li></ul><ul><li>Size of varices </li></ul><ul><li>High portal pr </li></ul><ul><li>Liver failure </li></ul><ul><li>Drugs </li></ul>
  33. 33. Management of acute variceal bleeding <ul><li>To restore circulation </li></ul><ul><li>Reduction of portal pressure </li></ul><ul><li>Local measures </li></ul>
  34. 34. Reduction of portal pressure <ul><li>Less important >sclerotherapy or banding </li></ul><ul><li>Pharmacological measures </li></ul><ul><li>vasopressin I/V 0.4 U/min x 24 hrs </li></ul><ul><li> 0.2 U/min x 24 hrs </li></ul><ul><li>Terlipression 2mg iv 6hrly </li></ul><ul><li>1mg iv 6hrly x 24 hrs </li></ul><ul><li>Otreotide 50ug iv stat & hrly infusion </li></ul><ul><li>TIPSS & shunt surgery </li></ul><ul><li>-high mortality </li></ul>
  35. 35. Local measures <ul><li>Sclerotherapy or banding </li></ul><ul><li>daignostic endoscopy </li></ul><ul><li>stop bleeding in 80% of patients </li></ul><ul><li>can be repeated if bleeding recurs </li></ul><ul><li>Balloon tamponade </li></ul><ul><li>Sengstaken-Blakemore </li></ul><ul><li>Minnesota tube </li></ul><ul><li>Oesophageal transection </li></ul><ul><li>stapling gun </li></ul><ul><li>spleenectomy </li></ul>
  36. 36. Prevention of recurrent bleeding <ul><li>Sclerotherapy </li></ul><ul><li>sclerosing agents </li></ul><ul><li>1-2 weekly </li></ul><ul><li>S/E fever </li></ul><ul><li> Transient chest pain/abdo </li></ul><ul><li> Transient dysphagia </li></ul><ul><li> oesophageal perforation </li></ul><ul><li>Low mortality </li></ul>
  37. 37. Prevention of recurrent bleeding <ul><li>Banding </li></ul><ul><li>occluded with tight rubber band </li></ul><ul><li>More effective </li></ul><ul><li>Fewer S/E </li></ul>
  38. 38. Prevention of recurrent bleeding <ul><li>TIPSS </li></ul><ul><li>Stent placed b/t portal vein &hepatic vein in the liver </li></ul><ul><li>under radiological contol </li></ul><ul><li>t/h Internal jugular vein </li></ul><ul><li>Prior angiography </li></ul><ul><li>FFP </li></ul><ul><li>Antibiotic cover </li></ul><ul><li>S/E Shunt narrowing/occlusion </li></ul><ul><li>Hepatic encephalopathy </li></ul>
  39. 39. <ul><li>Portasystemic shunt surgery </li></ul><ul><li>High mortality </li></ul><ul><li>Non-selective shunt </li></ul><ul><li>Postop liver failure </li></ul><ul><li>Hepatic encephalopathy </li></ul><ul><li>More selective shunt </li></ul><ul><li> less post hepatic encephalopathy </li></ul><ul><li>Preserved for patients in whom other treatments have not been successful </li></ul>
  40. 40. <ul><li>Propranolol </li></ul><ul><li>80-160mg/day, </li></ul><ul><li>Not widely used:Poor compliance </li></ul><ul><li>use for primary prevention </li></ul><ul><li>Child-pugh grading and risk of variceal bleeding </li></ul><ul><li>points 1 2 3 </li></ul><ul><li>Bilirubin( µmol/l) <34 34-51 >51 </li></ul><ul><li>Albumin(g/l) >3.5 2.8-3.5 <2.8 </li></ul><ul><li>PT(seconds>normal) 1-3 4-6 >6 </li></ul><ul><li>Ascites None slight moderate </li></ul><ul><li>Encephalopathy None 1-2 3-4 </li></ul><ul><li>Points ≥ 8  risk </li></ul>
  41. 41. Congestive gastropathy <ul><li>Endoscopy </li></ul><ul><li>multiple areas of punctate erythema </li></ul><ul><li>distally GIT </li></ul><ul><li>erosion –bleeding </li></ul><ul><li>IDA </li></ul><ul><li>Treatment </li></ul><ul><li>propranolol </li></ul><ul><li>TIPSS </li></ul>
  42. 42. MCQ <ul><li>1.Clinical features of cirrhosis of the liver includes </li></ul><ul><li>Hepatomegaly </li></ul><ul><li>Jaundice </li></ul><ul><li>Palmer erythema </li></ul><ul><li>Amenorrhoea </li></ul><ul><li>Low grade fever </li></ul>
  43. 43. MCQ <ul><li>2.Complications of cirrhosis are </li></ul><ul><li>Portal hypertension </li></ul><ul><li>Ascites </li></ul><ul><li>Hepatic encephalopathy </li></ul><ul><li>Renal failure </li></ul><ul><li>Bacteraemia </li></ul>
  44. 44. MCQ <ul><li>3.Poor prognostic factors includes </li></ul><ul><li>Hypoalbuminaemia </li></ul><ul><li>Hypernatraemia </li></ul><ul><li>Increasing total bilirubin </li></ul><ul><li>Prolonged prothrombin time </li></ul><ul><li>Cirrhosis due to haemochromatosis </li></ul>
  45. 45. MSQ <ul><li>What are the common causes of cirrhosis </li></ul><ul><li>of liver? How would you manage a case of </li></ul><ul><li>COL with hepatic encephalopathy? </li></ul>
  46. 46. MCQ <ul><li>1.Clinical features of portal hypertension are </li></ul><ul><li>Splenomegaly </li></ul><ul><li>Hypersplenism </li></ul><ul><li>Jaundice </li></ul><ul><li>Fetor hepaticus </li></ul><ul><li>Spider naevi </li></ul>
  47. 47. MCQ <ul><li>2. Following drugs can be used in acute variceal bleeding </li></ul><ul><li>Vasopressin </li></ul><ul><li>NSAID </li></ul><ul><li>Terlipressin </li></ul><ul><li>Octreotide </li></ul><ul><li>Beta blocker </li></ul>
  48. 48. MSQ <ul><li>Describe management of acute GI bleeding due to rupture oesophageal varices.What preventive measures would you give to prevent recurrent bleeding? </li></ul>

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