Chronic Liver Disease

Long Case Approach to Chronic Liver Disease
Identify the Aetiology & their Risk Factors

1. Infections Hepatitis B, C
2. Alcohol / drugs (MTX, amiodarone)
3. Metabolic
a. DO NOT mention haemochromatosis. Gene not found in local population
b. Wilsons disease
c. Alpha1 antitrypsin deficiency
4. Congenital / hereditary biliary atresia
5. Autoimmune usually female
6. Cryptogenic
Diagnosing CLD based on:
1. Stigmata of CLD jaundice, clubbing, leukonychia, palmar erythema, spider naevi,
gynaecomastia, testicular atrophy
2. Symptoms of CLD jaundice, ascites, pedal edema, Cx of CLD, non-specific
symptoms (LOW, LOA, malaise)
3. Radiological/ Histological results
4. LFT
Assessing CLD
Is the CLD
i.
Compensated
ii.
Decompensated presence of Cxs of CLD
Child-Pugh score for prognostication & assessment of CLD severity

Criteria
Points
Total S. Bilirubin
1
<2
(mg/dl)
2
2-3
3
>3
S. Albumin
1
>3.5
(g/dl)
2
2.8-3.5
3
<2.8
INR
1
<1.70
2
1.71-2.20
3
>2.20
Ascites
1
No ascites
2
Ascites controlled medically
3
Ascites poorly controlled
Encephalopathy
1
No encephalopathy
2
Encephalopathy medically controlled
3
Encephalopathy poorly controlled
Child Class
Prognosis
A (5-6 pts)
Life expectancy 15-20
yrs
Abdo Sx peri-op
mortality: 10%
B (7-9 pts)
Indicated for liver
transplant evaluation
Abdo Sx peri-op
mortality: 30%
C(10-15 pts)
Life expectancy 1-3 yrs
Abdo Sx peri-op
mortality: 82%
Identify Complications of CLD (ABCDE + HP)
Albumin (hypo)
Bilirubin - jaundice
Coagulopathies
Distension (ascites)
Encephalopathy
HCC
Hepatorenal synd
Hepatopulm synd
Heart failure
Portal HTN varices
Portal vein thrombosis

Common Presentations
i.
Swelling ascites, pedal edema
ii.
Abdominal pain
iii. Upper GI bleed due to bleeding oesophageal varices or Mallory-Weiss tear after
alcoholic binge
iv. Encephalopathy
v. CCF secondary to CLD
vi. HCC enlarged abdominal mass
History
Common presenting complaints:
Jaundice
GI bleed ddx: peptic ulcer, drugs, Mallory Weiss, CA
Petechiae many present initially ITP-like
Ascites ddx: cardiac, renal, malabsorption
Encephalopathy ask about pptg causes (hemorrhage/ hypoxia/ hypnotics/ hard stools/
infections/ CA see below for complete list)
Symptoms of
CLD
Abdominal pain
Jaundice
Non-specific symptoms (LOW,
pruritis
LOA, malaise)
If viral hepatitis usually due to malignancy or SBP
If EtOH hepatitis usually due to stretching of liver capsule or pancreatitis
(often after alcoholic binge).
Complications of CLD (ABCDE+ portal HTN + CA)
hypoAlb
Abdominal swelling
LL swelling
Bilirubin
jaundice
pruritis
Coagulopathy
Bruising
Menorrhagia
Epistaxis
Bleeding gums
Distension
Ascites
SBP
Encephalopathy Lethargy / drowsiness / LOC
Sleep-wake cycle reversal
Limb rigidity & hyperreflexia
Personality change
Sensory neuropathy
Seizures
Asterixis
Portal HTNs
varices
Cancer
Causes of CLD
Alcohol
Hepatitis
Hemetemesis oeso variceal bld

Symptoms of shock dizziness,
Melaena black, tarry formless
LOC, SOB
stool
LOW/ LOA
Is regular f/u done? U/S, AFP DGIM Last updated March 2005
CAGE questionnaire
Present drinking hx no. of
units/wk >14 male, >7 female
Past drinking hx
Hx of hepatitis & treatment
Hx of Hepatitis B vaccination
Signs to look for in CLD

CLD & complications
Hands
Clubbing
Pallor
Cyanosis
Leuconychia
Arms / chest
Bruises / petechiae
Gynaecomastia
Head
Jaundice
Pallor
Alopecia
Abdomen /
Ascites
pelvis
tenderness SBP,
pancreatitis, malignancy, liver
capsule stretch
Legs
Rectum
Hepatic
Encephalopathy
Other cx of
alcoholism
Pedal oedema
Melaena
Occupation esp bartender,

waiter, seamen, military
Recent alcoholic binge
IVDA/Tattoos/transfusions
CSW/ Homosexuality
Palmar erythema EtOH liver dz

Dupuytrens contractures
Asterixis
Postural tremors EtOH liver dz
Spider naevi >5 in area of
drainage of SVC
Parotid enlargement EtOH liver
dz
Fetor hepaticus
Caput medusae
Hepatomegaly tenderness, note
especially if liver irregular, hard
Splenomegaly
Testicular atrophy
Hard stools (encephalopathy)
Test for orientation to TPP

4 stages of encephalopathy
Stage I: sleep-wake reversal, slurred speech, slow mentation
Stage II: irritability, asterixis, lethargy, disorientation, personality
Stage III: confusion, sleepy by responds to pain & voice
Stage IV: coma, unresponsive to voice pain
Cardiac
displaced apex
CCF
Neuro/Psy
Neuro examPeripheral neuropathy,
--Wernickes encephalopathy (NOA+confusion)
o
Horizontal nystagmus
o
Ophthalmoplegia
o
Ataxia (test gait)
MMSE dementia
--Korsakoffs psychosis
o
Impaired recall & learning abilities
o
Confabulation
o
Intact consciousness
Investigations
To confirm dx
To look for etiology
To look for complications

FBC
Hypersplenism HB, leucocytes, pltlets
Anaemia megaloblastic (Vit B12 or folate deficiency), Fe

deficiency
Infections SBP
LFT
Confirm dx
GGT suggests alcoholic liver disease
S. albumin and bilirubin for Child-Pugh classification

PT/aPTT
INR for Child-Pugh classification

AFP
HCC
U/S HBS
HCC
CXR
Malignancies
Liver biopsy
Confirm dx
HCC
Paracentesis
Microscopy, C/S, amylase
Malignant cells, infections (SBP), pancreatitis

Hepatitis serology
Cause of CLD
Other causes of
Autoantibodies
CLD
Urinary Cu (Wilsons disease)

Management of CLD
1. Ascites / pedal oedema
2.
Spontaneous Bacterial
Peritonitis
3.
Varices
Non pharmacological
Fluid & salt restriction
I/O charting, daily wt measurement
Pharmacological
Diuretics spironolactone +/- frusemide
Procedural
Paracentesis diagnostic & therapeutic (SOB)
If leucocyte count >250cells/mm3, give fluoroquinolone
Acute onset abdominal pain, rebound tenderness, absent
bowel sounds and fever in the presence of ascites &
cirrhosis
Invx: paracentesis cloudy fluid with neutrophils count
>250/mm3
Usually enteric organisms, esp E. Coli
Rx: cefuroxime + metronidazole
Prophylaxis with ciprofloxacin
Acute variceal bleed
4.
Encephalopathy
5.
HCC
6.
Malnutrition
Resuscitate, stabilize, optimize for endoscopy

ABC
Fluid resus 2 large bores
Bloods FBC/ PT/aPTT/ GXM/ UECr/ LFT
Get ready FFP/VitK/pRBC
IV omeprazole, also somatostatin (Ocreotide)/ terlipressin
if GI bleed suspected to be varices
Urgent endoscopy for banding/ligation
IV glypressin
90% can be treated by endoscopy
DGIM
5% need re-endoscopic
tx Last updated March 2005
5% need surgical TIPS/ esophageal resection/ gastric
repair
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 state
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 dependence
Vit K injection
Vit D and Ca supplements
Extra information
Factors precipitating Hepatic encephalopathy
Uraemia spontaneous or diuretic
induced
K+
Drugs sedative/narcotics,
antidepressants, hypnotics
GI bleeding
Excessive dietary protein
Constipation
Paracentesis (>3-5L) leads to

hypovolaemia and K+
Infections
Trauma / Sx
Portasystemic shunts
EtOH binge
DGIM Last updated March 2005

Chronic Liver Disease

Uploaded by

Copyright:

Available Formats

Chronic Liver Disease

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Chronic Liver Disease

Uploaded by

Copyright:

Available Formats

What are the common presentations of chronic liver disease?

What are the common presentations of chronic liver disease?

What are the complications of chronic liver disease?

What are the complications of chronic liver disease?

Long Case Approach to Chronic Liver Disease

Identify the Aetiology & their Risk Factors

Child-Pugh score for prognostication & assessment of CLD severity

Identify Complications of CLD (ABCDE + HP)

Portal HTN varices

Portal vein thrombosis

Hemetemesis oeso variceal bld

Signs to look for in CLD

Occupation esp bartender,

Palmar erythema EtOH liver dz

Hard stools (encephalopathy)

Test for orientation to TPP

To look for etiology

To look for complications

Hypersplenism HB, leucocytes, pltlets

Anaemia megaloblastic (Vit B12 or folate deficiency), Fe

GGT suggests alcoholic liver disease

S. albumin and bilirubin for Child-Pugh classification

INR for Child-Pugh classification

Microscopy, C/S, amylase

Malignant cells, infections (SBP), pancreatitis

Urinary Cu (Wilsons disease)

Resuscitate, stabilize, optimize for endoscopy

Uraemia spontaneous or diuretic

Paracentesis (>3-5L) leads to

DGIM Last updated March 2005

You might also like