Chronic liver disease long Flashcards
Complications of chronic liver disease
Cirrhosis Portal HTN (ascites/SBP, varices, hypersplenism) HCC Bleeding Portal vein thrombosis
What to ask about monitoring for chronic liver disease
Liver function (fibroscan, LFT, ultrasound), HCC, endoscopies
Pharmacological therapy for portal hypertension
Propanolol
comorbidities of diabetes, heart failure, arthropathy in CLD - what to think of
haemachromatosis
Treatment of chronic liver disease
Protein restriction, fluid restriction, alcohol abstinence, steroids, lactulose, neomycin
Common perioperative complications in chronic liver disease
complications (eg ascites, encephalopathy) and mortality are higher in patients with cirrhosis
consider the sodium content of fluids, adjust doses of analgesia and sedation, avoid postoperative constipation
How to assess if ascites is from cirrhosis?
Serum ascites albumin gradient > 11g/L (might be <11g/L in SBP)
Treatment of ascites
- Sodium restriction
- Spironolactone/amiloride
- Frusemide
- More invasive - recurrent paracentesis, TIPS, transplantation
What are precipitants of hepatorenal syndrome
Infection (SBP) Nephrotoxics Diuretics GI Bleeding Large volume paracentesis
Management of hepatorenal syndrome
Correct precipitants
Correct hypovolaemia - STOP DIURETICS
Terlipressin, albumin
Consider liver transplant
Management of bleeding varices
Aim Hb 70-80
Terlipression/octreotide
Gastroscopy in 12 hours
TIPS if ongoing bleeding
Prevention for hepatic encephalopathy
lactulose 30mg TDS, rifaximin 550mg daily
Monitoring for HCC
US every 6 months
Indications for referral to liver transplantation
Consider referring patients with refractory ascites, an episode of spontaneous bacterial peritonitis or hepatorenal syndrome, recurrent or chronic hepatic encephalopathy, small hepatocellular carcinomas or significant malnutrition to a transplant team. Additionally, patients should be referred to a transplant team if they have one of the following:
a Child-Turcotte-Pugh score (based on degree of ascites, encephalopathy, serum bilirubin, albumin and international normalised ratio [INR]) of B7 or above
a Model for End-stage Liver Disease (MELD) score (based on serum bilirubin, creatinine and INR) of 13 or above
HOWEVER - most ETOH liver cirrhosis recompensate
Reasons that ETOH liver disease do not recompensate
o Inadequate nutrition
o Pancreatic dysfunction - Fecal elastase
o Ongoing alcohol
o Secondary liver pathology (most commonly NASH)
What diet should chronic liver disease patients be on
Low salt high protein
Often need evening snack
What is an early sign of encephalopathy
Reversal of sleep cycle
Chronic liver disease examination
General inspection, mental state, ethnicity, cachexia
Stigmata of chronic liver disease and portal hypertension Flap Fluid retenion - ascities Evidence of HCC Aetioogy of liver disease
What is the LFT ratio in alcoholic liver disease
AST: ALT >2.0
Causes of anaemia in chronic liver disease
blood loss, iron def, folate def, bone marrow suppression, hypersplenism
Causes of ascites
SAAG > 11g/l:
- cirrhosis
- Alcoholic hepatitis
- Cardiac ascites (RHF/constrictive pericarditis)
- Budd-chiari syndrome/inferior IVC obstruction
Not related to portal hypertension (SAAG <11g/L):
- cancer
- TB
- Pancreatitis
- nephrotic syndrome
What is the characteristic of dyspnoea in hepatopulmonary syndrome
Platypnoea - dyspnoea is worse when sitting up and relieved by lying down
What tests for a liver screen
AMA, ANA, anti-LKM1, anti-smooth muscle antibody, iron studies, caeruloplasmin levels, protein electrophoresis for alpha 1 fracture, hepatitis
Risk factors of variceal bleeding
Child pugh C
Gross ascites
Large varices
When is TIPS contraindicated
Encephalopathic patients
