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Acute and Chronic Liver Disease

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Acute and Chronic Liver Disease Dr. Orla Crosbie Consultant Gastroenterologist, CUH 4th Med, 17th Nov 2010 Contents Investigations Acute Liver disease Chronic Liver ... – PowerPoint PPT presentation

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Title: Acute and Chronic Liver Disease


1
Acute and Chronic Liver Disease
  • Dr. Orla Crosbie
  • Consultant Gastroenterologist, CUH
  • 4th Med, 17th Nov 2010

2
Contents
  • Investigations
  • Acute Liver disease
  • Chronic Liver Disease

3
Normal Liver Function
  • Protein synthesis and degradation
  • albumin, transport proteins, clotting factors,
  • Carbohydrate metabolism
  • Lipid metabolism
  • Bile acid metabolism
  • Bilirubin metabolism
  • Hormone inactivation
  • Drug inactivation and excretion
  • Immunological function

4
Liver function tests 1
  • Bilirubin Conjugated and Unconjugated
  • ALT/AST levels
  • Alkaline Phosphatase
  • gGT
  • Albumin
  • INR
  • FBC

5
Liver function tests 2
  • Hepatitis antibodies A, B, C.D, E
  • EBV, Toxo, CMV, Leptospirosis
  • Ferritin and fasting transferrin saturation,
  • Haemochromatosis genetics
  • Caeruloplasmin and copper (serum),
  • 24 hour urine for copper
  • Autoantibodies ANA, ASMA, AMA, Coeliac
  • Immunoglobulins IgG, IgA, IgM
  • Cholesterol, triglycerides, glucose, TFTs
  • a1antitrypsin levels phenotype
  • a-fetoprotein (cirrhotics only)

6
Imaging
  • Ultrasound Liver substance, lesions,
    gallbladder and biliary tree, vessels (Doppler
    exam), spleen size and varices
  • CT scan confirm small lesions, see pancreas
  • MRI of Liver classify smaller lesions
  • MRCP Magnetic resonance cholangiopancreatography,
    to see the biliary tree
  • ERCP Endoscopic retrograde cholangiopancreatograp
    hy diagnostic and therapeutic stones,
    strictures etc.

7
MRCP
8
ERCP
9
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10
Liver Biopsy
  • Very useful for confirming a diagnosis, staging
    degree of inflammation and/or fibrosis, iron
    content, mass lesions
  • Contraindications Bleeding disorders, ascites,
    small liver, uncooperative patient
  • Complications Bleeding, pain, perforation
    another viscus, biliary leak, pneumothorax
  • Methods Percutaneous, transjugular,
    laparoscopically

11
Jaundice
  • Pre hepatic
  • Haemolysis
  • Conjugation abnormalities
  • Hepatic any liver disease, acute or chronic
  • Post hepatic Obstruction

12
Gilberts syndrome
  • Deficient glucuronyl transferase
  • Unconjugated hyperbilirubinaemia, other LFTs
    normal
  • 2-5 population
  • Jaundice when dehydrated
  • Low grade haemolysis
  • Normal liver, life expectancy etc.

13
Acute Liver Disease
  • Infections
  • Viral Hepatitis A, B, C, D, E, EBV, CMV, HSV,
  • Others Leptospirosis, Toxoplasma,
  • Drugs MANY HERBALS/OTC
  • Alcohol
  • Poisons
  • Vascular obstruction (eg. Budd Chiari)

14
Acute Liver Disease
  • SYMPTOMS
  • Nausea vomiting, diarrhoea, cholestasis,
    pyrexia, abdominal pain, jaundice
  • Fulminant/acute liver failure rare, patient very
    unwell coagulopathy and encephalopathic
  • SIGNS
  • Jaundice, hepatomegaly, abdominal tenderness
    splenomegaly, flap/foetar

15
Acute Liver Disease treatment
  • Supportive mainly
  • Remove precipitating cause if known eg. drugs
  • Treat some cases eg. Leptospirosis, some viral
    infections in acute phase,
  • Expect complications and treat as they arise eg
  • Infection
  • Bleeding
  • Outcome
  • Resolve
  • Worsen and develop FLF (? Transplant)
  • Progress to chronic liver disease, may require
    specific therapy

16
Paracetamol toxicity
  • Present in many preparations
  • 10gms (20 tablets) can cause fatal liver failure
  • Initial NV often settles with symptoms of liver
    failure developing 2-3 days later
  • Coagulopathy and raised ALT
  • Paracetamol levels may be low/neg by this stage
  • High index of suspicion
  • Treat if in any doubt with N-acetylcysteine

17
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18
Chronic Liver Disease
  • Alcohol
  • Autoimmune autoimmmune hepatitis, PBC (Primary
    Biliary cirrhosis), PSC (Primary Sclerosing
    Cholangitis)
  • Haemochromatosis
  • Chronic Viral hepatitis B C
  • Non-alcoholic fatty liver disease (NAFLD)
  • Drugs (MTX, amiodarone)
  • Cystic fibrosis, a1antitryptin deficiency,
    Wilsons disease,
  • Vascular problems (Portal hypertension liver
    disease)
  • Cryptogenic
  • Others sarcoidosis, amyloid, schistosomiasis

19
Chronic Liver Disease - symptoms
  • None
  • Fatigue
  • Malnutrition
  • Ascites, ankle oedema, pleural effusions weight
    gain
  • Impotence
  • Bleeding
  • Jaundice, itch, steatorrhoea

20
Alcohol
  • Fatty liver may have no symptoms
  • Alcoholic Hepatitis can be unwell with liver
    and renal failure, jaundice, coagulopathy
  • Cirrhosis and its complications
  • Can present at any stage above
  • ACCURATE ALCOHOL HISTORY
  • Clues LFTS gGT, MCV
  • Other problems medical (pancreatitis,
    malnutrition, infections, cardiac), social.

21
Tx. Of Alcoholic Hepatitis
  • Feed (Enterally)
  • Vitamin replacement Thiamine IV Pabrinex and
    multivitamins
  • Treat DTs
  • Corticosteroids if Maddreys discriminant
    function higher than 32
  • 50 mortality rate
  • mDF 4.6 x (PT patient-control) Bilirubin/17.1
    umol/L
  • Treat with steroids Prednisolone 40mg X1/12
  • Other scoring systems Glasgow Alcoholic
    Hepatitis Score, MELD score

22
Fatty Liver
  • Many Secondary causes of fatty liver, including
    drugs, alcohol, previous surgery
  • Primary fatty liver or non-alcoholic fatty liver
    disease (NAFLD) commonly recognised now
  • Some patients in addition to fat on liver biopsy
    can have inflammation as well (steatohepatitis)
    and are referred to as NASH (non- alcoholic
    steatohepatitis), a portion of these will develop
    scarring and can progress to cirrhosis over time
  • Is associated with obesity, non-insulin dependent
    diabetes, dyslipidaemia and hypertension
    considered part of syndrome X/metabolic syndrome
  • Fatty liver getting more common obesity
    increasing.

23
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25
Hereditary haemochromatosis
  • Commonest genetic problem N. European
  • Progressive iron overload leading to liver
    disease (cirrhosis and hepatocellular carcinoma),
    diabetes, pigmentation, arthropathy,
    hypogonadism, cardiac.
  • Not always symptomatic at diagnosis

26
Hereditary haemochromatosis
  • Need high serum ferritin level and fasting
    transferrin saturations to make diagnosis
  • Fasting Transferrin Saturation gt 45
  • Raised Serum Ferritin gt 350ug/L
  • Genetics C282Y and H63D mutation
  • REMEMBER MANY CAUSES OF RAISED FERRITIN

27
Hereditary haemochromatosis
  • If HH confirmed
  • LFTs and ultrasound /- Liver biopsy to diagnose
    Cirrhosis
  • Prognosis worse if diabetic or cirrhotic at time
    of diagnosis
  • If cirrhotic, need tumour surveillance
  • Treatment is phlebotomy to render iron deficient
    and prevent organ damage, does not remove risk of
    HCC
  • Life long

28
Chronic Liver Disease - Decompensation
  • Ascites renal failure
  • GI bleeding
  • Encephalopathy
  • Jaundice
  • Hepatocellular carcinoma

29
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31
Ascites
  • Associated with a poor prognosis
  • Often associated with ankle oedema, pleural
    effusions
  • Diagnostic paracentesis 1. Biochemistry, 2.
    Micro 3. Cytology
  • SAAG Serum albumin/ascites gradient gt 11g/dl
  • Risk of Spontaneous Bacterial Peritonitis
  • Therapy
  • Low salt diet
  • Diuretics Spironolactone and Frusemide
  • Therapeutic large volume paracentesis albumin
    replacement
  • Shunts TIPS
  • Transplantation
  • DAILY WEIGHTS, WATCH UEs
  • Dont fluid restrict

32
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33
Spontaneous Bacterial Peritonitis
  • Risk Ascites and Chronic liver disease
  • Often vague symptoms
  • Diagnosis Diagnostic paracentesis for
  • WCC gt 250 cells/mm3 and mainly polymorphs
  • Culture
  • Usually Gram negatives
  • Treat antibiotics /- albumin
  • Antibiotic prophylaxis

34
Variceal bleeding
  • Due to portal hypertension
  • Varices at porto-systemic anastomoses
  • Skin Caput medusa
  • Oesophageal Gastric
  • Rectal
  • Posterior abdominal wall
  • Stomal
  • Medical emergency

35
Resuscitate patient Good IV access Cross-match
blood and clotting factors Emergency OGD
36
Band oesophageal varices Can Inject gastric
varices with glue Manage in HDU/ITU Terlipressin
IV Prophylactic antibiotics U/sound and doppler
portal vein Rebleed Rescope, Balloon
tamponade, May need TIPPs shunt, transplant
37
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38
Prevention of variceal haemorrhage
  • PRIMARY PREVENTION Have not bled
  • Scope all cirrhotics
  • If large varices B block with Propranolol or
    Band varices.
  • SECONDARY PREVENTION After bleed
  • Repeat banding until varices eradicated /-
    propranolol (ideally measure portal pressures)

39
Encephalopathy
  • Confusion due to liver disease
  • Graded 1-4
  • Precipitants GI bleed, infection, constipation,
    dehydration, medication esp. sedation
  • Flap asterixis and hepatic foetar
  • Treat underlying cause,
  • Laxatives phosphate enemas and lactulose
  • Rifaximin-broad non absorbed spectrum antibiotic

40
Hepatorenal syndrome
  • Progressive renal failure in the setting of
    advanced liver disease and portal hypertension
  • Rule out other causes for renal failure
    Pre-renal, Microscopy, ultrasound
  • Type 1 (acute) and Type 2 (chronic)
  • Very poor prognosis

41
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43
Hepatocellular Carcinoma (Hepatoma)
  • Primary Liver Cancer
  • Usually in setting of cirrhosis
  • Risk factors Viral hepatitis B/C, Alcohol,
    haemochromatosis, a1 anti-trypsin, male PBCs
  • Screen cirrhotics with 6 monthly u/sound and
    afetoprotein levels
  • Diagnosis made on imaging (u/s, CT or MRI) and
    aFP levels in cirrhotics biopsy usually not
    done
  • Cure transplant or surgery
  • Palliation TACE, radiofrequency ablation,
    Sorafenib po.

44
Liver transplantation
  • INDICATIONS
  • Fulminant Liver failure determined by certain
    clinical criteria (Kings criteria)
  • Paracetamol Overdose pH, INR, creatinine and
    Encephalopathy
  • Non-paracetamol INR, Bilirubin, age, cause,
    encephalopathy
  • Chronic Liver Disease Mainly for Decompensation
  • ascites
  • Uncontrolled variceal haemorrhage
  • Encephalopathy
  • Hepatoma Milan criteria
  • Disease specific criteria Rising Bilirubin in
    PBC
  • Need to consider Q of Life and Other illnesses

45
Liver transplantation
  • WAITING LIST MELD scoring system
  • Liver Matched by blood group and size
  • Post operative
  • Immunosuppression to prevent rejection eg.
    Tacrolimus, Mycophenolate and Steroids
  • Prophylaxis against infection eg. CMV, HSV, PCP
  • Can get graft failure, vascular thrombosis,
    rejection (acute and chronic), infections,
    disease recurrence

46
Liver disease summary
  • LFTs
  • Causes of jaundice
  • Causes of acute hepatitis
  • Causes of cirrhosis Risk factors
  • Symptoms and Signs of liver disease Ascites,
    encephalopathy SBP, variceal haemorrhage, HCC
    and hepatorenal syndrome.
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