Detailed about about psychiatric manifestation of liver disorders and how to manage depression in these patients.

1. LIVER DISAESE AND
PSYCHIATRIC DISORDER
DR ZOHAIB ABBASI
RESIDENT INTERNAL MEDICINE

3. WHICH CAME FIRST
• A patient came to physician for disturbed sleep.On further inquiry there was
history of low mood, slowness of motor activity, loss of interest in routine
work. Other routine labs shows HBA1C 7.0 and us abdomen shows fatty
liver?
• A patient admitted with psychotic symptoms for 4 weeks and diagnosed as
schizophrenia .His labs shows hep c positive. No Any evidence for CLD

4. Which came first
• A patient previously treated for hep B present with disturbed sleep.US
abdomen shows coarse echopattern, one of the feature of cirhosis.what to
do next?
• We must assess whether these symptoms are due to hep enceph or due to
depression/anxiety??

5. CLD VS DCLD
• CLD- chronic progressive inflammation, ranges from chronic infection upto
cirrhosis.
• DCLD- when there is portal hypertension ( ascites, esophageal varices), or
hepatic insufficiency ( hepatic enceph, jaundice)

6. HEPATIC ENCEPH
• COVERT/ MINIMAL HE
• GRADE 0- psychometric or neuropsychological alteration of test exploring
psychomotor speed/executive function without mental cahnge. These patient
will present in ortho, neurosurgery, maxillofacial ward due to road traffic
accident.
• GRADE I-trivial lack of awareness, euphoria or anxiety, shortened attention
span, altered sleep rhythm.

7. • GRADE II- DISORIENTATION FOR TIME, LETHARGY OR
APATHY, INAPPROPRIATE BEHAVIOUR, OBVIOUS PERSONALITY
CHANGE
• GRADE III-SEMISTUPOR, GROSS DISORIENTATION,
RESPONSIVE TO STIMULI, BIZARE BEHAVIOUR.
• GRADE IV- COMA

8. HOW TO ASSESS MINIMAL/COVERT HE
• PHES- evaluating cognitive and psychomotor processing speed and visuo-
motor coordination. There are six test, the easy one are NCT-A and DST
OTHER TEST WHICH WE COMMONLY PERFORMED ARE TO DRAW
A CLOCK

10. PSYCHIATRIC ILLNESS VS HE
• WE SHOULD DIFFERENTIATE WHETHER PSYCHIATRIC
SYMPTOMS ARE DUE TO HEPATIC ENCEPH OR DUE TO
PSYCHIATRIC DISORDER.
• IN HE, SYMPOMS ARE NEUROPSYCHIATRIC

11. MANAGEMENT OF HE
• REMOVING CAUSE FOR CIRRHOSIS.
• CONCURRENT ILLNESS WHICH CAN EXACERBATE CIRRHOSIS
LIKE ANY INFECTION.
• AVOID CONSTIPATOP. 2,3 TIMES STOOLS PER DAY.
• TAB. RIFAXIMIN
• UPPER GI ENDOSCOPY FOR BAND LIGATIN.

12. MANAGEMENT OF ANXIETY IN CLD
• Two points should be kept in mind
• 1. SSRI increased the risk of GI bleed, we must add PPI.
• 2.Initial dose will be same but for maintainance we should not double the
dose until indicated.
• But main point is still that we should kept in mind regarding HE.
• And benzodiazepines should be avoided, it will shift patient from grade 0/1
to 2/3/4.

13. MANAGEMENT OF DEPRESSIN IN CLD

14. Wilson disease
• This disease is due to accumulation of copper in liver, cornea, brain and vital
organs.
• 1/3 of patient present only with psychiatric symptoms.
• Urinary copper and serum ceruloplasmin should be checked in young
people. Atleast we should do workup in treatment resistant cases.

15. • Hepatitis c itself can cause psychosis and other psychiatric symptoms. Agin
same lesson.
• Interferon, a drug used in treatment of hepatitis also causes psychiatric
symptoms.

16. CONCLUSION
• Dr Jamil is very true regarding the place of psychiatry ward. It should not be
far away from medical services.
• Every psychiatric should get opinion from physician, neurophysician prior to
prescribing psychiatric medication.
• CLD and hepatitis are our national disease, psychiatrist must rule out
hepatitis b, c and cld by just two blood screening test and one ultrasound
abdomen.

17. THANKYOU
ANY QUESTION?