Chronic Liver Disease

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Long Case Approach to Chronic Liver Disease Identify Complications of CLD (ABCDE + HP)

 Albumin (hypo)
Identify the Aetiology & their Risk Factors  Bilirubin - jaundice
1. Infections – Hepatitis B, C  Coagulopathies
2. Alcohol / drugs (MTX, amiodarone)  Distension (ascites)
3. Metabolic  Encephalopathy
a. DO NOT mention haemochromatosis. Gene not found in local population  HCC
b. Wilson’s disease  Hepatorenal synd
c. Alpha1 antitrypsin deficiency  Hepatopulm synd
4. Congenital / hereditary – biliary atresia  Heart failure
5. Autoimmune – usually female  Portal HTN – varices
6. Cryptogenic  Portal vein thrombosis

Diagnosing CLD – based on:


1. Stigmata of CLD – jaundice, clubbing, leukonychia, palmar erythema, spider naevi, Common Presentations
gynaecomastia, testicular atrophy i. Swelling – ascites, pedal edema
2. Symptoms of CLD – jaundice, ascites, pedal edema, Cx of CLD, non-specific ii. Abdominal pain
symptoms (LOW, LOA, malaise) iii. Upper GI bleed – due to bleeding oesophageal varices or Mallory-Weiss tear after
3. Radiological/ Histological results alcoholic binge
4. LFT iv. Encephalopathy
v. CCF secondary to CLD
Assessing CLD vi. HCC – enlarged abdominal mass
 Is the CLD
i. Compensated History
ii. Decompensated – presence of Cxs of CLD Common presenting complaints:
 Child-Pugh score – for prognostication & assessment of CLD severity  Jaundice
Criteria Points  GI bleed – ddx: peptic ulcer, drugs, Mallory Weiss, CA
Total S. Bilirubin 1 <2  Petechiae – many present initially ITP-like
(mg/dl) 2 2-3  Ascites – ddx: cardiac, renal, malabsorption
3 >3  Encephalopathy – ask about ppt’g causes (hemorrhage/ hypoxia/ hypnotics/ hard stools/
S. Albumin 1 >3.5 infections/ CA – see below for complete list)
(g/dl) 2 2.8-3.5
3 <2.8 Symptoms of  Jaundice  Non-specific symptoms (LOW,
INR 1 <1.70 CLD  pruritis LOA, malaise)
2 1.71-2.20 Abdominal pain  If viral hepatitis – usually due to malignancy or SBP
3 >2.20  If EtOH hepatitis – usually due to stretching of liver capsule or pancreatitis
Ascites 1 No ascites (often after alcoholic binge).
2 Ascites controlled medically Complications of CLD (ABCDE+ portal HTN + CA)
3 Ascites poorly controlled hypoAlb  Abdominal swelling  LL swelling
Encephalopathy 1 No encephalopathy Bilirubin  jaundice  pruritis
2 Encephalopathy medically controlled Coagulopathy  Bruising  Menorrhagia
3 Encephalopathy poorly controlled  Epistaxis  Bleeding gums
Distension  Ascites  SBP
Child Class A (5-6 pts) B (7-9 pts) C(10-15 pts) Encephalopathy  Lethargy / drowsiness / LOC  Sleep-wake cycle reversal
Prognosis  Life expectancy 15-20  Indicated for liver  Life expectancy 1-3 yrs  Limb rigidity & hyperreflexia  Personality change
yrs transplant evaluation  Abdo Sx peri-op  Sensory neuropathy  Seizures
 Abdo Sx peri-op  Abdo Sx peri-op mortality: 82%  Asterixis 
mortality: 10% mortality: 30% Portal HTN’s  Hemetemesis – oeso variceal bld  Symptoms of shock – dizziness,
varices  Melaena – black, tarry formless LOC, SOB
stool

DGIM – Last updated March 2005


Cancer  LOW/ LOA
 Is regular f/u done? U/S, AFP Investigations
Causes of CLD  To confirm dx
Alcohol  CAGE questionnaire  Occupation – esp bartender,  To look for etiology
 Present drinking hx – no. of waiter, seamen, military  To look for complications
units/wk >14 male, >7 female  Recent alcoholic binge FBC  Hypersplenism – HB,  leucocytes, pltlets
 Past drinking hx  Anaemia – megaloblastic (Vit B12 or folate deficiency), Fe
Hepatitis  Hx of hepatitis & treatment  IVDA/Tattoos/transfusions deficiency
 Hx of Hepatitis B vaccination  CSW/ Homosexuality  Infections – SBP
LFT  Confirm dx
 GGT suggests alcoholic liver disease
 S. albumin and bilirubin for Child-Pugh classification
Signs to look for in CLD PT/aPTT  INR for Child-Pugh classification
CLD & complications
AFP  HCC
Hands  Clubbing  Palmar erythema – EtOH liver dz
U/S HBS  HCC
 Pallor  Dupuytren’s contractures
 Cyanosis  Asterixis CXR  Malignancies
 Leuconychia  Postural tremors – EtOH liver dz Liver biopsy  Confirm dx
Arms / chest  Bruises / petechiae  Spider naevi >5 in area of  HCC
 Gynaecomastia drainage of SVC Paracentesis  Microscopy, C/S, amylase
Head  Jaundice  Parotid enlargement – EtOH liver  Malignant cells, infections (SBP), pancreatitis
 Pallor dz Hepatitis serology  Cause of CLD
 Alopecia  Fetor hepaticus Other causes of  Autoantibodies
Abdomen /  Ascites  Caput medusae CLD  Urinary Cu (Wilson’s disease)
pelvis   tenderness – SBP,  Hepatomegaly  tenderness, note
pancreatitis, malignancy, liver especially if liver irregular, hard Management of CLD
capsule stretch  Splenomegaly 1. Ascites / pedal oedema Non pharmacological
 Testicular atrophy  Fluid & salt restriction
Legs  Pedal oedema  I/O charting, daily wt measurement
Pharmacological
Rectum  Melaena  Hard stools (encephalopathy)
 Diuretics – spironolactone +/- frusemide
Hepatic  Test for orientation to TPP Procedural
Encephalopathy  4 stages of encephalopathy  Paracentesis – diagnostic & therapeutic (SOB)
Stage I: sleep-wake reversal, slurred speech, slow mentation If leucocyte count >250cells/mm3, give fluoroquinolone
Stage II: irritability, asterixis, lethargy, disorientation, personality  2. Spontaneous Bacterial  Acute onset abdominal pain, rebound tenderness, absent
Stage III: confusion, sleepy by responds to pain & voice Peritonitis bowel sounds and fever in the presence of ascites &
Stage IV: coma, unresponsive to voice  pain cirrhosis
Other cx of Cardiac  Invx: paracentesis – cloudy fluid with neutrophils count
alcoholism  displaced apex >250/mm3
 CCF  Usually enteric organisms, esp E. Coli
Neuro/Psy  Rx: cefuroxime + metronidazole
 Neuro exam—Peripheral neuropathy,  Prophylaxis with ciprofloxacin
--Wernicke’s encephalopathy (NOA+confusion) 3. Varices Acute variceal bleed
o Horizontal nystagmus Resuscitate, stabilize, optimize for endoscopy
o Ophthalmoplegia  ABC
o Ataxia (test gait)  Fluid resus – 2 large bores
 MMSE – dementia  Bloods – FBC/ PT/aPTT/ GXM/ UECr/ LFT
--Korsakoff’s psychosis  Get ready FFP/VitK/pRBC
o Impaired recall & learning abilities  IV omeprazole, also somatostatin (Ocreotide)/ terlipressin
o Confabulation if GI bleed suspected to be varices
o Intact consciousness  Urgent endoscopy for banding/ligation
 IV glypressin
 90% can be treated by endoscopy
 5% need re-endoscopic tx – Last updated March 2005
DGIM
 5% need surgical TIPS/ esophageal resection/ gastric
repair
4. Encephalopathy  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
5. HCC  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
6. Malnutrition  Vit K injection
 Vit D and Ca supplements

Extra information

Factors precipitating Hepatic encephalopathy


 Uraemia – spontaneous or diuretic  K+
induced  Paracentesis (>3-5L) – leads to
 Drugs – sedative/narcotics, hypovolaemia and K+
antidepressants, hypnotics  Infections
 GI bleeding  Trauma / Sx
 Excessive dietary protein  Portasystemic shunts
 Constipation  EtOH binge

DGIM – Last updated March 2005

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