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Chronic liver disease
Multiple causes,
common manifestation
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
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
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
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
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
Management
To retard progression & reduce
complications
Abstinence from alcohol
Vaccination- Hep A & B
Treat underlying cause
Complications
 Ascites
 Spontaneous bacterial peritonitis- SBP
 Variceal bleed
 Hepatic encephalopathy
 Hepatorenal syndrome
 Hepatocellular carcinoma- HCC
Ascitis
 Diagnostic paracentesis- SAAG >1.1
 Cause-
 Portal HT
 Hypoalbuminemia
 Raised renin-angiotensin-aldosterone levels
causing Na retention by kidneys
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
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
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
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
Hepatic encephalopathy
 Confusiondrowsinessstuporcoma
 Ammonia is an identified/measurable toxin
 Precipitants-
 GI bleed
 Constipation
 Alkalosis, hypokalemia
 Sedatives
 Paracentesishypovolemia
 Infection
 TIPS
 Dx- clinical- s/s of CLD
with asterixis & altered sensorium
Management
 Correct underlying precipitating factor
 Avoid sedatives
 Restrict dietary protein intake
 Lactulose- 2-3 loose stools a day
 Oral antibiotic- Metronidazole,
Rifaximin, Neomycin
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
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
Liver transplantation
Option in ESLD
Donor, cost, technical expertise
GVHD, recurrence

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Chronic liver disease

  • 1. Chronic liver disease Multiple causes, common manifestation
  • 2. 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
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. Management To retard progression & reduce complications Abstinence from alcohol Vaccination- Hep A & B Treat underlying cause
  • 8. Complications  Ascites  Spontaneous bacterial peritonitis- SBP  Variceal bleed  Hepatic encephalopathy  Hepatorenal syndrome  Hepatocellular carcinoma- HCC
  • 9. Ascitis  Diagnostic paracentesis- SAAG >1.1  Cause-  Portal HT  Hypoalbuminemia  Raised renin-angiotensin-aldosterone levels causing Na retention by kidneys
  • 10. 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
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. Hepatic encephalopathy  Confusiondrowsinessstuporcoma  Ammonia is an identified/measurable toxin  Precipitants-  GI bleed  Constipation  Alkalosis, hypokalemia  Sedatives  Paracentesishypovolemia  Infection  TIPS  Dx- clinical- s/s of CLD with asterixis & altered sensorium
  • 15. Management  Correct underlying precipitating factor  Avoid sedatives  Restrict dietary protein intake  Lactulose- 2-3 loose stools a day  Oral antibiotic- Metronidazole, Rifaximin, Neomycin
  • 16. 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
  • 17. 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
  • 18. Liver transplantation Option in ESLD Donor, cost, technical expertise GVHD, recurrence