Gastro - Viva - Chronic Liver Disease Flashcards
Causes of chronic liver disease
Alcohol
Infective - Hep B and C
Drugs - Methotrextate, Methyldopa, Amiodarone
Cholestasis - Primary biliary cirrhosis, sclerosing cholangitis
Autoimmune hepatitis
Hereditary - Wilson, Haemachromatosis, a1 deficiency
Vascular - Budd -Chiari, veno- occlusive disease
Non Alcoholic Fatty Liver Disease NAFLD
Scoring systems in the prognostication of CLD
Child-Pugh Score
Model of End Stage Liver Disease (MELD)
SOFA can be used to discriminate survivors from non
UK Model for End Stage Liver Disease (UKELD) to aid selection of transplant candidate
Waht is the Child Pugh Score
Scored 1-3, 5 catergories
Encephalopathy –> None, Grade 1-2, Grade 3-4
Ascites None, Mild, severe (refractory)
Bilirubin <34, 34-50, >50
Albumin >35, 28-35, less than 28
INR <1.7, 1.7.- 23, >2.3
Grade A 5-6 points
B 7-9
C 10-15
Survival based on child pugh grades
A (5-6) 100% at 1 year, 85% at 2
B (7-9) 81% at 1, 57% at 2
C (10-15), 45% at 1, 35% at 2
MELD score
Predicts mortality in hospitalised patients with cirrhosis
MELD, taken from bilirubin, INR, creatinine
MELD = (3.78 x ln{bili])+(11.2x ln [INR}) + 9.57 (ln creatinine) + 6.43
Why do cirrhotic patients come to ICU
Management of bleeding varices Management of coagulopathy Alchoholic hepatitis AKI Severe sepsis
What is portal hypertension
Portal pressure > 10mmHg and is associated with :
porto-systemic collateral venous circulation
ascites
splenomegaly
Clinical diagnosis as portal pressure can only be diagnoised directly via a TIPSS
Main complication of portal hypertension
Varices leading to massive upper GI bleed
Treatment of variceal bleed
ABCDE treat as found
Specific:
Volume - transfuse blood and blood products
Vasoconstrictors - terlipressin (or?somatostatin)
Endoscopy within 24 hours using variceal band ligation
Prevent complication - antibiotics
and if you cants control bleed via OGD
Balloon tampanade via Sengstaken blakemore
Further endocscopy
TIPPS
Surgery
Consider TIPPS or transplant to prevent rebleeds
What is a TIPPS
Transjugular Intrahepatic Portosystemic Stent Shunt
What does a TIPPS do
Endovacular procedure
Makes a communication between the inflow portal vein and the outflow hepatic vein, using a stent.
Reduces portal pressure in patients with complications related to portal hypertension (bleeding, dieuretic resistant ascites)
Divert blood from hepatic vein, to reduce pressure gradient between portal and systemic circulations.
Also useful in encephalopathy to divert blood from liver
What is HepatoRenal Syndrome
Type of renal failure in patients with cirrhosis or fulminant liver failure.
It is a PRE-RENAL AKI that does not respond to fluids
Abnormal autoregulation with renal vasoconstircion due to sympathetic stimulation and dilation of splanchnic vessels.
What is the characteristic feature
Low fractional excretion of sodium with progressive rise in plasma creatinine in patient with CLD
Diagnostic criteria of HRS
Cirrhosis with ascites
Creatinie above 133
No improvement in creatinine after 2 days of dieurteitc withdrawel and volume expansion with albumin
No shock
No nephrotoxins
No renal parenchnymal disease
Types of HRS
2
Type 1- Rapidly progressive decline in kidney function with mortality > 50%
Type 2- More indolent course with dieuretic resistant ascites
Tx options for HRS
Trial of terlipressin and plasma expansion with albumin
TIPPS may improve renal function
Definative - tranplant
What is SBP
Ascitiv fluid infection without an evident intra-abdominal surgically treatable source
Almost always occurs in paitents with cirrhosis and ascites
Presenting features of SBP
non specific
Fever, hypotension, abdo pain, altered mental status
Fluid wcc?
Neutrophil greater than 250 cells/mm3 and / or positive periotoneal fluid cultures
Treatment of SBP
Empriic abx and local sensitivitys
Smal study shower terlipressin improved haemodynamics
Features of hepato-pulmonary syndrome
Poorly understood, with intrapulmonary shunting and hypoxia in patients with cirrhosis
Dyspnoea, hypoxia that are worse upright (platypnoea and orthodeoxia)
Poor prognosis
Indication for orthotopic liver transplant
What is alcholic hep
Syndrome of progressive inflammatory liver injury with long term alcohol use.
Severe alcoholic hep –> mortality of 50% in 30 days
How to diagnose alco hep
Hx of alcohol intake Fever worsening LFTs (inc raised bili and aminotransferases)
May not have cirrhosis
Tx of alco hep
Supportive
Steroid in severe cases –> reduce inflammation
Transfer to tertiary centre in severe cases
Pentoxyphyline reduces incidence of HRS in alco hep.
Abstinance in long term
Define chronic liver failure
Deterioration in hepatic synthetic and metabolic function of grater the 26 weeks duration
WITHOUT ENCEPHALOPATHY
Define acute on chronic liver failure
chronic liver disease who develops acute deterioration in liver function and organ dysfunction
Systemic manifestations of CLD
CVS - CAD, Cardiomyopathy, Cardiac Failure
Resp - Pulmonary Hypertension, fibrosis, VQ mismatch
Neuro - polyneuropathy, autonomic dysfunction, encepph
Endocrine _ DM, Thyroid Disease, hyper lipid
Haem - anaemia, hypersplenism, neutropenia, thrombocytopenia, coagulapathy
GI - portal gastropathy, varices,
Panc and biliary Ca
Renal - glomerularnephritis from hep virus nephropathy
HRS
Skin - pruritis, palmar erythema, spider naevia, porphyria curtanea tarda
Grading of encephalopathy
West Haven
1 - behaviour change without change in conciousness
2- drowsiness, disorintated
3 - Rousable to voice, confused, incoherent
4 - Coma, decorticate posturing
Scoring systems
MELD
Child Pugh
Features of Child Pugh
Bilrubin Albumin Ascites INR Enceph
Grades of Child pugh
A - 5-6
B - 7-9
C 10-15
Life expectancy by childs score
A - 15-20 years
B - 4 - 15 years
C - 1-2 years
Peri op motality rises ( 10%, 30%, 80% for laporotomy)
Meld features
INR plus bilirubin plus albumin
BUT
Add sodium if MELD > 12
MELD score points
> 9 refers to transplant centre
> 24 consider for transplant
What causes acute on chronic failure
Infection (bacterial, viral, funalg)
Alcolic hep
Trauma (surgery)
In 40%, no cause found
Predictors of mortality in acute on chronic
Age,
WCC
Degree of organ dysfunction
Critical care manamagent of acute on chronic
Supportive
ABCDE
Find the precipitating cause
Restore the circulating volume, maintain organ perfusion wiht vasoactives
?cardiac output monitor
Early Abx
Invasive fungaemia is rare –> fungal colonisers are not
Albumin
Adrenocortical failure is common but steroids do not improve mortality
HF to remove ammonia
Liver transplant - HOWEVER, no provision for emergency transplant in chronic failures
