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END STAGE LIVER DISEASE

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ESLD is usually manifested as cirrhosis of the liver, which is a progressive ... Ricahrd A. Wiklund, MD: Preoperative preparation of patients with advanced liver ... – PowerPoint PPT presentation

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Title: END STAGE LIVER DISEASE


1
END STAGE LIVER DISEASE
2
Discourse
  • What is end stage liver disease (ESLD)?
  • - Manifestation of ESLD
  • - Lab and radiologic investigations
  • - Complications of ESLD
  • What are the predictors of mortality in ESLD?
  • Treatment of Alcoholic liver disease.

3
What is ESLD?
  • ESLD is usually manifested as cirrhosis of
    the liver, which is a progressive fibronodular
    hyperplasia and bridging fibrosis that results in
    marginal synthetic hepatocellular function,
    cholestasis and variable degree of portal
    hypertension.

4
Epidemiology
  • ESLD accounted for over 25,000 deaths and 373,000
    hospital discharges in the United States in 1998.
    (The National Center for Health Statistics.)
  • It is responsible for about 2 of all death in
    the United States and may account for as much as
    1 of all health care spending

Clin Liver Dis 9 (2005) 103-134.
5
Causes of ESLD
  • They are myriad, but the most common causes
    include
  • Alcohol abuse
  • Viral infection
  • Autoimmune disease
  • Drug reaction
  • Genetic metabolic aberrations
  • Cholestasis
  • Inflammatory disease of the bile tracts.

6
Manifestation of ESLD
  • Spider telangiectasias
  • Palmar erythema
  • Nail changes
  • Dupuytren's contracture
  • Gynecomastia
  • Testicular atrophy
  • Hepatomegaly
  • Splenomegaly
  • Ascites
  • Caput medusae
  • Cruveilhier-Baumgarten murmur
  • Fetor hepaticus
  • Jaundice
  • Asterixis

7
Signs of ESLD
8
Constitutional Symptoms
  • Weakness
  • Fatigue
  • Anorexia and Weight Loss.
  • Other general features that may be seen include
  • Low grade fever
  • Pigment gallstones
  • Parotid gland enlargement
  • Diabetes mellitus

9
Laboratory findings
  • Aminotransferases -AST ALT
  • Alkaline phosphatase
  • Gamma-glutamyl transpeptidase (GGT)
  • Bilirubin
  • Albumin
  • Globulins
  • Serum sodium
  • Hematologic abnormalities
  • - Anemia
  • -Thrombocytopenia
  • -Leukopenia
  • -Neutropenia
  • -Coagulation defects
  • (PT INR)

10
 Radiography
  • Ultrasonography
  • "Stiffness" measurement (Fibroscan EchoSens)
  • Computed tomography (CT- Scan)
  • Magnetic resonance imaging (MRI)
  • Nuclear studies

11
Confirmative Diagnosis
  • The gold standard for diagnosis of cirrhosis is
    liver biopsy, the sensitivity of a liver biopsy
    for cirrhosis ranges from 80 to 100 depending
    on the method used, the size and number of
    specimens obtained.  

12
Complications of ESLD
  • Malnutrition
  • Encephalopathy
  • Coagulopathy
  • Portal Hypertension
  • Variceal Hemorrhage
  • Pulmonary Hypertension Hepatopulmonary syndrome
  • Hepatorenal Syndrome HRS
  • Spontaneous Bacterial Peritonitis SBP
  • Hyponatremia

13
Prognostic predictors in ESLD
  • Patients with ESLD can be stratified into
    different categories of risk based on hepatic
    synthetic reserve.
  • Some of the predicting models used in ESLD are -
  • Child's classification.
  • The Maddrey score
  • The model for end stage liver disease score (MELD
    score).

14
Childs Classification
  • On multivariate analysis, the Child-Pugh
    classification was the best predictor of surgical
    mortality and morbidity .
  • Class A cirrhosis - 10 mortality for elective
    surgery. (no particular restrictions)
  • Class B cirrhosis - 30 mortality. (tolerate
    elective surgery avoid major hepatic resections)
  • Class C cirrhosis - 75 mortality. (with
    abdominal surgery).

15
The Maddery score
  • Derived in clinical trials of patients with AH
    and used to stratify the severity of illness for
    the use of steroids in AH.
  • With hepatic encephalopathy, DF score gt32 is
    correlated with gt50 short-term mortality rate in
    AH.

Gut 2005541174-1179
16
The MELD score
  • The "model for end stage liver disease score"
    (MELD score) is a statistical model predicting
    survival in patients with cirrhosis.
  • There is a good correlation between the Childs
    classification and the MELD scores in predicting
    mortality, especially with emergency surgery.
  • The MELD score and the DF have similar
    sensitivities, although the MELD score has a
    higher specificity in predicting outcome in ESLD
  • In a report, A MELD score of 8 was useful for
    predicting morbidity after cholecystectomy.

Gut 2005541174-1179
17
The use of steroids in AH
  • Only patients with severe disease ( hepatic
    encephalopathy and/or DF gt32) should be treated
    with corticosteroids.
  • Despite the fact that treatment reduces the
    mortality risk by 25, there is still a 45
    mortality in patients receiving corticosteroids.
  • About seven patients need to be treated to avoid
    one death. Careful patient selection is important
    to avoid the side effects of steroids in the
    patients who will derive no clinical benefit from
    them.
  • Based on pharmacologic considerations,
    prednisolone (40 mg/d for 4 weeks then tapered
    over 24 weeks) should be used in favor of
    prednisone

Clin Liver Dis 9 (2005) 103-134
18
The use of steroids in ESLD
  • Most of the reports excluded patients who had
    active GI bleeding, infection, renal failure, or
    pancreatitis. Thus, the efficacy of
    corticosteroids patients with these
    characteristics has not been well studied.
  • In the evaluation of patients in whom
    corticosteroids are being considered for
    nonalcohol related liver disease (viral
    hepatitis), It is unclear what impact these
    infections would have on treatment outcome.
  • Careful monitoring for evidence of infection,
    gastrointestinal bleeding, glucose intolerance,
    or renal failure is essential while the patient
    is on prednisolone therapy.
  • In the patient who responds well and improves
    enough to merit hospital discharge, therapy is
    continued for the complete course, with at least
    weekly outpatient visits

Clin Liver Dis 9 (2005) 103-134
19
Effect of steroids in the management of severe AH
Clin Liver Dis 9 (2005) 103-134.
20
References
  • Alessandra Puggioni, MD Linda L Wong, MD, FACS
    A metaanalysis of laparoscopic cholecystectomy in
    patients with cirrhosis.Journal of the American
    College of Surgeons. Volume197.Number6.December
    2003.
  • Thomas W.Faust, MD K. Rajender Reddy, MD
    Postoperative jaundice. Clinics in Liver Disease.
    Volume 8. Number1. February 2004.
  • Ricahrd A. Wiklund, MD Preoperative preparation
    of patients with advanced liver disease. Critical
    Care Medicine. Volume 32. Number 4. April 2004.
  • Sipriya Balasubramanian, MD Kris V. Kowdley, MD
    Effect of Alcohol on Viral Hepatitis and other
    Forme of Liver Dysfunction. Clinics in Liver
    Disease. Volume 9. Number 1. February 2005.

21
References (contd)
  • E H Forrest, C D Evans, S Stewart, M Phillips, Y
    H Oo, N C McAvoy, N C Fisher, S Singhal, A Brind,
    G Haydon, J OGrady, C P Hayes, L S Murray, and A
    J Morris Analysis of factors predictive of
    mortality in alcoholic hepatitis and deprivation
    and validation of the Glasgow alcoholic hepatitis
    score. Gut 2005541174-1179 doi10.1136/gut.2004
    .050781.
  • Robert S. OShea, MD, MSCE Arthur J. McCullough,
    MD Treatment of Alcoholic Hepatitis. Clin Liver
    Dis 9 (2005) 103-134.
  • Chinnasamy Palanivelu, MS. Mch, MNAMS, FACS,
    FRCS Pidigu Seshiyer Rajan, MS, FACS, FICS
    Kaplesh Jani, MS, DNB, MNAMS Alangar Roshan
    Shetty, MS, FICS Karuppasamy Sendhilkumar, MS,
    FACS, FICS Palanisamy Senthilnathan, MS
    Ramakrishnan Parthasarthi, MBBS Laparoscopic
    Cholecystectomy in Cirrhotic Patients the Role
    of Subtotal Cholecystectomy and its Variants.
    Journal of the American College of Surgeons.
    Volume 203. Number 2. August 2006.

22
Thank you!
23
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