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Chronic liver disease and substance misuse

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Chronic liver disease and substance misuse Kapil Kapur Department of gastroenterology BDGH NFT Introduction Definition Aetiology of chronic liver disease Symptoms and ... – PowerPoint PPT presentation

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Title: Chronic liver disease and substance misuse


1
Chronic liver disease and substance misuse
  • Kapil Kapur
  • Department of gastroenterology
  • BDGH NFT

2
Introduction
  • Definition
  • Aetiology of chronic liver disease
  • Symptoms and signs of chronic liver disease
  • Complications in chronic liver disease
  • Investigations in chronic liver disease
  • Chronic liver disease and substance misuse
  • Alcoholic liver disease
  • Hepatitis C
  • Hepatitis B

3
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4
Liver cirrhosis
  • Cirrhosis represents a late stage of progressive
    liver fibrosis and disease and results in a
    distortion of liver architecture
  • Usually changes are irreversible
  • Liver transplantation may be the only option

5
Aetiology
  • Alcoholic liver disease
  • Fatty liver disease (NAFLD)
  • Hepatitis B and C
  • Auto-immune liver disease
  • Primary biliary cirrhosis
  • Metabolic conditions
  • Hemochromatosis
  • Alpha 1 AT deficiency
  • Wilsons disease

6
Symptoms of chronic liver disease
  • Asymptomatic
  • General symptoms
  • fatigue, wt loss, poor nutrition, general
    ill-health, non-specific symptoms
  • Abnormal LFTs
  • Symptomatic
  • asymptomatic
  • Symptoms of liver failure
  • Jaundice
  • Ascites (swelling in the abdomen)
  • Encephalopathy

7
Symptoms of chronic liver disease
  • Symptoms of complications
  • Variceal bleeding
  • Portal hypertension
  • Spontaneous bacterial peritonitis (SBP)
  • Hepato-cellular cancer
  • Hepato-renal syndrome

8
Signs of chronic liver disease
  • No signs in early stages
  • Stigmata of compensated chronic liver disease
  • Spider naevi, clubbing, liver palms, poor
    nutrition,
  • Gynaecomastia and poor secondary sexual
    characteritics
  • Oedema (swelling) feet

9
Spider naevi
10
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11
Signs in chronic liver disease
  • Signs of decompensation / complications
  • Jaundice
  • Ascites and oedema feet
  • Encephalopathy
  • Confusion to coma
  • Upper GI bleeding
  • Haematemesis and or melaena
  • collapse

12
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13
Signs of Liver Disease
14
Signs of liver disease
15
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16
Complications of chronic liver disease
  • Upper gastrointestinal bleeding
  • Oesophageal varices
  • Gastric varices
  • Jaundice
  • Ascites, bacterial peritonitis and oedema
  • Encephalopathy
  • Hepatorenal syndrome
  • Liver cancer

17
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18
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19
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20
Oesophageal varices after application of rubber
bands
21
Gastric varices
22
Gastric varix after injection of histoacryl glue
23
Assessing severity
24
Child-Pugh Classification
  • 1 yr survival 2 yr survival
  • 5/6 ? A 100 85
  • 7-9 ? B 80 60
  • 10-15 ? C 45 35

25
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26
Prognostic impact of SBP
Probability
Survival in months
27
Investigations in chronic liver disease
  • Ultrasound abdomen
  • Non invasive liver screen (NILS)
  • LFTS and Prothrombin time
  • Hepatitis B and C serology
  • Autoimmune profile and immunoglobulins
  • Ferritin
  • Alpha 1 AT, Caeruloplasmin
  • Alpha feto protein

28
Investigations in chronic liver disease
  • Liver biopsy
  • Needle biopsy
  • Under X-ray control
  • Risks of bleeding and organ injuries

29
A general approach to management in chronic
disease
  • Establish the diagnosis
  • Treatment of acute symptoms and complications
  • Addressing the underlying cause
  • Alcohol, Hep B, Hep C
  • Explore role for transplantation
  • Surveillance for hepato-cellular cancer

30
Substance misuse and liver disease
  • Alcohol
  • Hepatitis C
  • Hepatitis B

31
Acute alcoholic hepatitis
  • Acute alcoholic hepatitis
  • Abstinence
  • Supportive therapy
  • Steroids
  • Pentoxifylline

32
Chronic alcoholic liver disease
  • Abstinence
  • Detox
  • Alcohol liaison services and support
  • Nutrition and vitamins
  • Symptom management
  • ? Transplantation if abstinent for 6 months

33
The course of alcoholic cirrhosis
  • Compensated cirrhosis
  • N 122
  • Decompensated disease, with ascites
  • in 58 at 10 years
  • 5 year survival abstainers 50 - 75
  • 5 year survival recalcitrants10 - 30

34
Hepatitis C
  • IVDU, contaminated needles, transfusion related
  • Confirm the diagnosis
  • RNA PCR
  • Viral load and genotype
  • Address risk factors
  • Antiviral therapy
  • Ribavirin
  • Pegylated interferon

35
Hep C treatment in Barnsley
  • We currently offer antiviral treatment and accept
    direct referrals
  • Expensive and prolonged and demanding
  • Difficult population to treat
  • Finite duration of treatment
  • Risk of re-infection
  • Nurse led clinicHep C Nurse

36
Current figures for Barnsley
  • 94 patients given treatment
  • 17 patients discontinued treatment
  • 52 patients have completed treatment
  • 39 patients had 6 month post Rx PCR
  • 33/39 sustained viral response (SVR)
  • 6/39 relapsed

37
Hepatitis B
  • IVDU, Infected sexual contacts, transfusion
    related
  • Vast majority need follow up rather than
    treatment
  • Business case for treatment in BDGH
  • Treatment is suppressive rather than curative
  • Prolonged antiviral therapy
  • Interferon,
  • AntiviralsLamivudine, Tenofovir

38
Summary
  • Chronic liver disease comprises a big burden for
    health care
  • Alcohol, Hepatitis C and Hepatitis B are
    important public health care issues
  • Important to recognise and treat chronic liver
    disease
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