Transcript Chronic Liver Disease

Chronic Liver
Disease
Simon Lynes
Definition
• Progressive destruction and regeneration of the liver
parenchyma leading to fibrosis and cirrhosis
Aetiology
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Vascular – Budd Chiari
Infectious – viral hepatitis B and C
T
Autoimmune – PBC/PSC, autoimmune hepatitis
Metabolic – Wilsons, Haemochromatosis, fatty liver
Iatrogenic - meds
Neoplasm
C
Drugs – e.g. ALCOHOL, antibiotics, methotrexate, amiodarone
Presentation – 2 types
• Compensated:
• Stigmata of chronic liver disease
• Gynaecomastia
• Spider Naevi
• Clubbing
• May have no symptoms or vague:
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RUQ pain
Pruritis
Fatigue
Oedema
• Synthetic function tests e.g. PT, albumin may be NORMAL
• Some abnormalities of LFTs e.g. ALT
• Decompensated
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Encephalopathy
Jaundice
Ascites
Asterisks
Investigations
• Bedside
• BM
• Bloods
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Serology
Autoantibodies
Ceruloplasmin, ferritin/transferrin/TIBC
Alpha fetoprotein
• Imaging
• USS and doppler of portal vein
• Special Tests
• Biopsy
• OGD - ?varices
• Ascitic tap
A LIVE CATCH
Alpha fetoprotein
LFTs
Igs
Viral hepatitis
Ethanol
Ceruloplasmin
Autoantibodies
Transferrin and Ferritin
CMV/EBV
HIV
Management
• Conservative
• Salt restriction
• Avoid alcohol
• Vaccinations
• Medication
• Diuretics
• Calcium/Vit D
• Surgical
• Paracentesis
• Transplant
• TIPSS
• *3-6 monthly screening for HCC*
Prognosis
• Child-Pugh classification
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PT
Albumin
Bilirubin
Ascites
Encephalopathy
• ‘Pour Another Beer At Eleven’
Interpreting LFTs
• Hepatic vs. post hepatic/obstructive
• ALT vs alk phos/gamma GT
• Synthetic function
• Albumin – chronic
• PT - acute
• Bilirubin
• Gamma GT – for alcohol (if alk phos normal)
Clinical scenario
54 year old gentleman presents to his GP with
increasing swelling of his abdomen and feet
over the last 2 months. He has been
increasingly tired over this time and feels
nauseous and is off his food. His wife has
commented that his eye have turned yellow
over the last few days. He works in a
warehouse and smokes 10 cigarettes a day. He
admits to drinking 4 cans of lager a night. His
wife says he drinks at least 8 cans a night and a
bottle of whiskey a week. On examination he
is jaundiced but has no hepatic flap and is
orientated in time, place and person. His
abdomen is distended but soft and nontender. There is no palpable organomegaly but
there is shifting dullness
• Differential Diagnoses?
• Investigations?
• Management?
Complications
• Decompensation
• Encepalopathy
• Jaundice
• Hepatocellular carcinoma
• Increased portal pressure
• Varices/GI bleed – exacerbated by decreased clotting
• Ascites
• SBP
• Hepatorenal syndrome
Encephalopathy
• Key features:
• Reversal of sleep patterns
• Confusion/drowsiness
• Asterisks and positive babinski
• Due to ammonia
• Treat with lactulose
SBP
• Suspect in sudden deterioration/pyrexia in patient with ascites
• Therepeutic tap
• >250 neutrophils per microlitre
• Broad spectrum antibiotics
• Albumin
GI Bleed
• Signs and symptoms:
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Haematemesis/malaena
Signs and symptoms of anaemia
+/- abdominal pain
+/- haemodynamic instability
• Blood tests:
• Low Hb – and raised urea
• Management
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A-E
Rockall/Blatchford score
Terlipressin, broad spectrum antibiotics for varices
Endoscopy
• Any questions?