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Recognition and management of advanced liver disease.pptx
- 1. Recognition and management of advanced liver disease Dinesh Jothimani Director, Hepatology Division Institute of Liver disease and Transplantation Dr Rela Institute & Medical Centre
- 2. Types of liver disease • Acute hepatitis • <3 months • Chronic hepatitis • >6 months
- 3. Types of liver disease • Acute hepatitis • <3 months • Chronic hepatitis • >6 months • Subacute hepatitis • 3-6 months
- 4. Acute Hepatitis Hepatitis A Hepatitis E Jothimani 2023
- 5. Acute Hepatitis Hepatitis A Hepatitis E Drug induced Liver injury
- 6. Acute Hepatitis- stages Acute Liver Failure Acute Liver injury Acute Hepatitis Prodrome Fever Nausea Vomiting Diarrhea myalgia Jaundice Jaundice Coagulopathy Jaundice Coagulopathy Hepatic encephalopathy
- 7. Acute Hepatitis- stages Acute Liver Failure Acute Liver injury Acute Hepatitis 95% 4% 1% Treatment None None Close follow up ALF protocol in ICU
- 8. Acute Hepatitis- stages Acute Liver Failure Acute Liver injury Acute Hepatitis Jaundice Jaundice Coagulopathy Jaundice Coagulopathy Hepatic encephalopathy 95% 4% 1%
- 9. Chronic Hepatitis • Liver injury lasts >6 months • Causes • Non-alcohol related fatty liver disease • Alcohol • Viral • Autoimmune liver disease • Metabolic disorders • Vascular disorders
- 10. NAFLD is a major health problem worldwide 2021
- 11. Fatty Liver vs Alcohol?
- 12. Fatty Liver vs Alcohol? NAFLD and ALD can be differentiated Only with history
- 13. Liver disease do not cause symptoms The disease process may take up to 15-20 years
- 14. Viral Hepatitis • Hepatitis B • DNA virus • Chronic hepatitis • May progress to cirrhosis • Most common cause of Hepatocellular carcinoma worldwide • Hepatitis C • RNA • Chronic hepatitis • Progresses to cirrhosis • High incidence of HCC
- 15. Chronic liver disease May take 30-40 years to develop
- 16. Chronic liver disease timeline Chronic Hepatitis Cirrhosis Decompensated cirrhosis Symptoms None
- 17. Chronic liver disease timeline Chronic Hepatitis Cirrhosis Decompensated cirrhosis Symptoms None LFT High ALT
- 18. Chronic liver disease timeline Chronic Hepatitis Cirrhosis Decompensated cirrhosis Symptoms None LFT High ALT Timeline 30 years
- 19. Chronic liver disease timeline Chronic Hepatitis Compensated Cirrhosis Decompensated cirrhosis Symptoms None LFT High ALT None Normal Timeline 30 years 10 years
- 20. Chronic Hepatitis vs Cirrhosis Symptoms None LFT High ALT None Normal Investigations LFT Viral serology Autoimmune markers US abdomen Fibroscan Liver biopsy LFT Viral serology Autoimmune markers CBC AFP US abdomen Fibroscan Treatment Underlying cause
- 21. Hepatitis B treatment- controls the disease Hepatitis C treatment- cures the disease
- 22. Chronic liver disease timeline Chronic Hepatitis Compensated Cirrhosis Decompensated cirrhosis Symptoms None LFT High ALT None Normal Timeline 30 years 10 years Tiredness Leg swelling Jaundice Ascites HE Variceal bleed HCC 2 years
- 23. Decompensated cirrhosis Development of portal hypertension is the hall mark of Hepatic decompensation Ascites Splenomegaly Esophageal varices Hepatic encephalopathy Sarcopenia LFT: synthetic failure High bilirubin Low albumin High INR Low platelets High risk of variceal bleed High risk of HCC Risk of sepsis Higher chance of death
- 24. Decompensated cirrhosis Development of portal hypertension is the hall mark of Hepatic decompensation Ascites Splenomegaly Esophageal varices Hepatic encephalopathy Average Life span: only 2 years LFT: synthetic failure High bilirubin Low albumin High INR Low platelets Treatment: Liver Transplantation
- 25. Can you identify patients before the next stage? Chronic Hepatitis Compensated Cirrhosis Decompensated cirrhosis
- 26. Can you identify patients before the next stage? Chronic Hepatitis Compensated Cirrhosis Decompensated cirrhosis Yes
- 27. Clinically Significant Portal Hypertension Plus Platelet count Jothimani 2023 MCNA
- 28. Chronic liver disease timeline Chronic Hepatitis Compensated Cirrhosis Decompensated cirrhosis Symptoms None LFT High ALT None Normal Timeline 30 years 10 years Tiredness Leg swelling Jaundice Ascites HE Variceal bleed HCC 2 years Acute on chronic liver failure Can occur at any stage
- 29. Summary • Acute • Jaundice alone= Acute hepatitis • Jaundice + Coagulopathy= Acute Liver injury • Jaundice + Coagulopathy + Hepatic Encephalopathy= Acute Liver Failure • Chronic • Chronic hepatitis= no symptoms- elevated ALT • Cirrhosis= no symptoms- normal LFT- irregular liver in US abdomen • Decompensated cirrhosis=symptomatic- deranged liver synthetic function- poor survival- needs liver transplantation
- 30. Cases • 45 year old • Obese, diabetic • No symptoms • ALT 70 • HBsAg + • US abdomen: normal liver • Diagnosis? • 45 year old • Obese, diabetic • No previous symptoms • Fever, jaundice • Bilirubin 7 mg • ALT 900 • US abdomen: enlarged liver • Diagnosis? Acute Hepatitis ALF Chronic hepatitis Cirrhosis Decompensated cirrhosis options
- 31. Cases • 45 year old • Obese, diabetic • Ascites • ALT 70 • HBsAg + • US abdomen: irregular liver, ascites • Diagnosis? • 45 year old • Obese, diabetic • No previous symptoms • Fever, jaundice • Bilirubin 7 mg • ALT 900 • INR 2.3 • Altered sensorium • US abdomen: enlarged liver • Diagnosis? Acute Hepatitis ALF Chronic hepatitis Cirrhosis Decompensated cirrhosis