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chronic_liver_disease.ppt
- 1. Chronic Liver Disease For final year medical students 2014 Dr Rosalind Pool GPST1
- 2. Objectives • List signs and symptoms of CLD • List causes of CLD • Understand LFTs • How to investigate CLD • Management of CLD • Apply knowledge to a case study.
- 3. Why might you suspect liver failure?
- 4. Why might you suspect liver failure? Drowsiness / Encephalopathy Jaundice Ascites / Oedema Excess alcohol Drugs Liver flap (use imagination!)
- 5. Causes of CLD • Write down causes • Try to structure your list.
- 6. Causes of liver disease • Toxins – Alcohol – Drugs e.g. paracetamol overdose, co-amoxiclav etc • Infections – Viral hepatitis, EBV, CMV • Metabolic – Wilson’s, Haemochromatosis, Alpha 1 antitrypsin deficiency • Neoplastic – Hepatocellular carcinoma, liver secondaries • Autoimmune – Autoimmune hepatitis – PBC, PSC • Vascular – Budd chiari
- 7. ‘Liver screen’ • What is included in a liver screen? • Think about your differential diagnoses.
- 8. Liver screen • LFTs • FBC, U&E, clotting • Hepatitis serology • EBV, CMV • Immunoglobulins • Glucose • Ceruloplasmin • ANA, AMA, alpha-1 antitripsin antibodies • AFP • Ferritin
- 9. Interpreting LFTs • Buzz groups List LFTs in the following categories • Hepatic • Cholestatic • Synthetic
- 10. LFTs • Hepatic – Transaminase enzymes (ALT, AST, GGT) • Cholestatic – ALP, Bilirubin • Synthetic – Albumin, INR
- 11. Investigations • Bedside tests • Bloods • More complex biochemistry • Radiology • Endoscopy
- 12. Investigations • Daily weights • Liver screen • USS doppler liver – portal blood flow and masses, hepatic vein patency • Ascitic tap – Microscopy and culture – Cell count – Biochemistry – Cytology • OGD – urgent if suspected UGIB otherwise surveillance. • Liver biopsy
- 14. Complications of CLD • Infection: – Spontaneous bacterial peritonitis – Sepsis • Ascites • Dehydration • respiratory distress • AKI • Encephalopathy • Bleeding – Oesophageal varices – Clotting abnormalities • Renal failure – AKI – Hepato-renal syndrome • Malnutrition – High risk of refeeding syndrome
- 15. Management • Conservative – Low salt, high protein diet, avoid alcohol • Medical – Diuretics – Human albumin solution – Paracentesis – Vitamins • Surgical – TIPS (Transjugular intrahepatic portosystemic shunt) – Transplant
- 16. What is this and why? Gynaecomastia… from spironolactone
- 17. Case study • 54 year old gentleman presents to his GP with: • 2/12 Hx increasing swelling of his abdomen and feet • Tired over this time and feels nauseous and is off his food. • His wife has commented that his eye have turned yellow over the last few days. • He works in a warehouse and smokes 10 cigarettes a day. • He admits to drinking 4 cans of lager a night. His wife says he drinks at least 8 cans a night and a bottle of whiskey a week. • On examination he is jaundiced but has no hepatic flap and is orientated in time, place and person. His abdomen is distended but soft and non- tender. There is no palpable organomegaly but there is shifting dullness
- 18. • What are your main differential diagnoses for this gentleman? (include all important differentials that must be ruled out) • How would you investigate this gentleman? • What would your management plan be for this gentleman?
- 19. • What are the features of hepatic encephalopathy? • How do you manage hepatic encephalopathy? • What are the complications of CLD? • What is Spontaneous Bacterial Peritonitis? • How would you manage an acute GI bleed (in the context of CLD)?
- 20. Summary • Signs, symptoms, causes, investigations and management of CLD • Understanding LFTs • Case study to apply your knowledge. Any questions?
- 21. Many thanks • Please fill in an evaluation form!