Chronic liver disease ( concise long case approach )


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Chronic liver disease ( concise long case approach )

  1. 1. Long Case Approach to Chronic Liver Disease Identify Complications of CLD (ABCDE + HP) Albumin (hypo)Identify the Aetiology & their Risk Factors Bilirubin - jaundice 1. Infections – Hepatitis B, C Coagulopathies 2. Alcohol / drugs (MTX, amiodarone) Distension (ascites) 3. Metabolic Encephalopathy a. DO NOT mention haemochromatosis. Gene not found in local population HCC b. Wilson’s disease Hepatorenal synd c. Alpha1 antitrypsin deficiency Hepatopulm synd 4. Congenital / hereditary – biliary atresia Heart failure 5. Autoimmune – usually female Portal HTN – varices 6. Cryptogenic Portal vein thrombosisDiagnosing CLD – based on: 1. Stigmata of CLD – jaundice, clubbing, leukonychia, palmar erythema, spider naevi, Common Presentations gynaecomastia, testicular atrophy i. Swelling – ascites, pedal edema 2. Symptoms of CLD – jaundice, ascites, pedal edema, Cx of CLD, non-specific ii. Abdominal pain symptoms (LOW, LOA, malaise) iii. Upper GI bleed – due to bleeding oesophageal varices or Mallory-Weiss tear after 3. Radiological/ Histological results alcoholic binge 4. LFT iv. Encephalopathy v. CCF secondary to CLDAssessing CLD vi. HCC – enlarged abdominal mass Is the CLD i. Compensated History ii. Decompensated – presence of Cxs of CLD Common presenting complaints: Child-Pugh score – for prognostication & assessment of CLD severity ♦ Jaundice Criteria Points ♦ GI bleed – ddx: peptic ulcer, drugs, Mallory Weiss, CA Total S. Bilirubin 1 <2 ♦ Petechiae – many present initially ITP-like (mg/dl) 2 2-3 ♦ Ascites – ddx: cardiac, renal, malabsorption 3 >3 ♦ Encephalopathy – ask about ppt’g causes (hemorrhage/ hypoxia/ hypnotics/ hard stools/ S. Albumin 1 >3.5 infections/ CA – see below for complete list) (g/dl) 2 2.8-3.5 3 <2.8 Symptoms of Jaundice Non-specific symptoms (LOW, INR 1 <1.70 CLD pruritis LOA, malaise) 2 1.71-2.20 Abdominal pain If viral hepatitis – usually due to malignancy or SBP 3 >2.20 If EtOH hepatitis – usually due to stretching of liver capsule or pancreatitis Ascites 1 No ascites (often after alcoholic binge). 2 Ascites controlled medically Complications of CLD (ABCDE+ portal HTN + CA) 3 Ascites poorly controlled hypoAlb Abdominal swelling LL swelling Encephalopathy 1 No encephalopathy Bilirubin jaundice pruritis 2 Encephalopathy medically controlled Coagulopathy Bruising Menorrhagia 3 Encephalopathy poorly controlled Epistaxis Bleeding gums Distension Ascites SBPChild Class A (5-6 pts) B (7-9 pts) C(10-15 pts) Encephalopathy Lethargy / drowsiness / LOC Sleep-wake cycle reversalPrognosis Life expectancy 15-20 Indicated for liver Life expectancy 1-3 yrs Limb rigidity & hyperreflexia Personality change yrs transplant evaluation Abdo Sx peri-op Sensory neuropathy Seizures Abdo Sx peri-op Abdo Sx peri-op mortality: 82% Asterixis mortality: 10% mortality: 30% Portal HTN’s Hemetemesis – oeso variceal bld Symptoms of shock – dizziness, varices Melaena – black, tarry formless LOC, SOB stool
  2. 2. Cancer LOW/ LOA Investigations Is regular f/u done? U/S, AFP To confirm dxCauses of CLD To look for etiologyAlcohol CAGE questionnaire Occupation – esp bartender, To look for complications Present drinking hx – no. of waiter, seamen, military FBC Hypersplenism – ↓HB, ↓ leucocytes, ↓pltlets units/wk >14 male, >7 female Recent alcoholic binge Anaemia – megaloblastic (Vit B12 or folate deficiency), Fe Past drinking hx deficiencyHepatitis Hx of hepatitis & treatment IVDA/Tattoos/transfusions Infections – SBP Hx of Hepatitis B vaccination CSW/ Homosexuality LFT Confirm dx ↑GGT suggests alcoholic liver disease S. albumin and bilirubin for Child-Pugh classificationSigns to look for in CLD PT/aPTT INR for Child-Pugh classificationCLD & complications AFP HCCHands Clubbing Palmar erythema – EtOH liver dz U/S HBS HCC Pallor Dupuytren’s contractures CXR Malignancies Cyanosis Asterixis Liver biopsy Confirm dx Leuconychia Postural tremors – EtOH liver dz HCCArms / chest Bruises / petechiae Spider naevi >5 in area of Paracentesis Microscopy, C/S, amylase Gynaecomastia drainage of SVC Malignant cells, infections (SBP), pancreatitisHead Jaundice Parotid enlargement – EtOH liver Hepatitis serology Cause of CLD Pallor dz Other causes of Autoantibodies Alopecia Fetor hepaticus CLD Urinary Cu (Wilson’s disease)Abdomen / Ascites Caput medusaepelvis ± tenderness – SBP, Hepatomegaly ± tenderness, note Management of CLD pancreatitis, malignancy, liver especially if liver irregular, hard 1. Ascites / pedal oedema Non pharmacological capsule stretch Splenomegaly Fluid & salt restriction Testicular atrophy I/O charting, daily wt measurementLegs Pedal oedema PharmacologicalRectum Melaena Hard stools (encephalopathy) Diuretics – spironolactone +/- frusemideHepatic Test for orientation to TPP ProceduralEncephalopathy 4 stages of encephalopathy Paracentesis – diagnostic & therapeutic (SOB) Stage I: sleep-wake reversal, slurred speech, slow mentation If leucocyte count >250cells/mm3, give fluoroquinolone Stage II: irritability, asterixis, lethargy, disorientation, personality Δ 2. Spontaneous Bacterial Acute onset abdominal pain, rebound tenderness, absent Stage III: confusion, sleepy by responds to pain & voice Peritonitis bowel sounds and fever in the presence of ascites & Stage IV: coma, unresponsive to voice ± pain cirrhosisOther cx of Cardiac Invx: paracentesis – cloudy fluid with neutrophils count 3alcoholism displaced apex >250/mm CCF Usually enteric organisms, esp E. Coli Neuro/Psy Rx: cefuroxime + metronidazole Neuro exam—Peripheral neuropathy, Prophylaxis with ciprofloxacin --Wernicke’s encephalopathy (NOA+confusion) 3. Varices Acute variceal bleed o Horizontal nystagmus Resuscitate, stabilize, optimize for endoscopy o Ophthalmoplegia ABC o Ataxia (test gait) Fluid resus – 2 large bores MMSE – dementia Bloods – FBC/ PT/aPTT/ GXM/ UECr/ LFT --Korsakoff’s psychosis Get ready FFP/VitK/pRBC o Impaired recall & learning abilities IV omeprazole, also somatostatin (Ocreotide)/ terlipressin o Confabulation if GI bleed suspected to be varices o Intact consciousness Urgent endoscopy for banding/ligation IV glypressin
  3. 3. 90% can be treated by endoscopy 5% need re-endoscopic tx 5% need surgical TIPS/ esophageal resection/ gastric repair4. Encephalopathy Identify precipitating factor and treat it – hemorrhage/ hypoxia/ hypercarbia/ hard stools/ hypnotics/ infections/ progression to CA Low protein diet Lactulose – aim to achieve at least 2-3 loose stools/day MARS (Membrane Adsorbent Recirculating System) – for acute liver failure. Able to restore liver function only to pre-morbid state5. HCC Sx resection preferred but only for o Child A/B, o unilobar CA with no portal vein involvement Therapeutic radiology only if Sx impossible o Transarterial chemoembolism (TACE) o Percutaneous ethanol injection Liver transplant indications o ESLD o Fulminant o HCC o Metabolic disease Contraindications o Mets o Severe comorbidities o HIV o Active HBV o Alcohol dependence6. Malnutrition Vit K injection Vit D and Ca supplementsExtra informationFactors precipitating Hepatic encephalopathy ↓K + Uraemia – spontaneous or diuretic Digitally signed by DR WANA HLA SHWE induced Paracentesis (>3-5L) – leads to DN: cn=DR WANA HLA SHWE, hypovolaemia and ↓K + Drugs – sedative/narcotics, c=MY, o=UCSI University, School of Medicine, KT-Campus, Terengganu, antidepressants, hypnotics Infections ou=Internal Medicine Group, GI bleeding Trauma / Sx Excessive dietary protein Reason: This document is for UCSI Portasystemic shunts year 4 students. Constipation EtOH binge Date: 2009.02.22 15:17:48 +0800