Liver Cirrhosis + Mx of CLD & Cx

Question 1

What is Liver Cirrhosis?

Answer 1

• Chronic inflammation which results in irreversible liver damage
• Liver cells replaced by scar tissue and nodules form within liver

Question 2

What are the causes of LC?

*think common, uncommon, autoimmune, drug causes

Answer 2

• Common
  
  • Alcoholic liver disease
  • Non-alcoholic fatty liver disease
  • Hep B
  • Hep C
• Uncommon
  
  • Haemochromatosis
  • Wilson’s disease
  • a-1 antitrypsin deficiensy
• Autoimmune
  
  • primary biliary cholangitis
  • primary sclerosing cholangitis
  • hepaitits
• Drugs
  
  • Amiodarone
  • Methotrexate
  • Sodium valporate

Question 3

What are the USS features of LC?

Answer 3

• Nodularity of the surface of the liver
• corkscrew appearance to the arteries
• Enlarged portal vein with reduced flow
• Ascites
• Splenomegaly

Question 4

What imaging is used as a screening tool for hepatocellular carcinoma and how often?

Answer 4

• USS
• every 6 months

Question 5

What scoring systems are used for LC?

Answer 5

• Child-Pugh score
  
  • min score: 5
  • max score: 15
  • paarmeteres: bilirubin, albumin, INR, Ascites, Encephalopathy
• MELD score
  
  • used every 6 months for compensated cirrhosis
  • parameters: bilirubin, creatinine, INR, sodium
  • help guide referral for dialysis
  • gives percentage estimate 3months mortality

Question 6

How would you Mx and monitor LC?

Answer 6

Monitor

• Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
• Endoscopy every 3 years in patients without known varices
• MELD score every 6 months

Lifestyle changes

• High protein, low sodium diet
• Alcohol abstinence
• Avoid NSAIDs, sedatives, opiods

Others

• Consideration of a liver transplant
• Managing complications as below

Question 7

What are the Cx of LC?

Answer 7

• Malnutrition
• Portal Hypertension, Varices and Variceal Bleeding
• Ascites and Spontaneous Bacterial Peritonitis (SBP)
• Hepato-renal Syndrome
• Hepatic Encephalopathy
• Hepatocellular Carcinoma
• Osteoporosis - offer DEXA scan

Question 8

What is the difference between compensated and decompensated LC?

Answer 8

• Compensated
  
  • no sx
• Decomepnsated
  
  • live unable to cope with insult - Sx develop

Question 9

What is the Px for Hepatic Encephalopathy?

Answer 9

1. Gut bacteria breakdown protein and form ammonia
2. Ammonia absorbed in gut
3. Impaired liver cells - unable to metabolise ammonia into harmless waste products
4. Ammonia bypass liver through collateral vessels formed between systemic and portal circulation

Question 10

How would you Mx hepatic encephalopathy?

Answer 10

• First line: Laxatives ( lactulose 15-20 mls QDS)
• Second line: Antibiotics - Rifaximin
• Nutritional support

Question 11

What is the Px of Hepatorenal syndrome?

Answer 11

1. Liver cirrhosis causes increase pressure in portal system
2. Dilation of portal veins - blood pooling occurs in this area
3. Decrease blood flow to kidneys and other areas
4. RAAS activated - renal vasoconstriction occur - further deteriorating blood supply to kidneys
5. Rapid deterioration of kidney function

Question 12

What is the presentation of spontaneous bacterial peritonitis (SBP)?

Answer 12

• asymptomatic
• Fever
• Abdominal pain
• Deranged bloods (raised WBC, CRP, creatinine or metabolic acidosis)
• Ileus
• Hypotension

Question 13

What are the common organisms that cause spontaneous bacterial peritonitis?

Answer 13

• Escherichia coli
• Klebsiella pnuemoniae
• Gram positive cocci (such as staphylococcus and enterococcus)

Question 14

How would you Mx SBP?

Answer 14

• Take an ascitic tap prior to giving antibiotics
• IV cephalosporin (cefotaxime)
• neutrophilic ascitic WCC >250
• Human albumin solution - prevent AKI and hepatorenal syndrome
• Prophylaxis - rifaximin

Question 15

What is the Px of Ascites in LC?

Answer 15

1. Increase pressure in portal system
2. Fluid leak out in capillaries in liver and bowel
3. Fluid loss into peritoneal space
4. Drop in circulating volume

Question 16

How would you mx ascites?

Answer 16

• Low sodium diet
• spironolactone +/- furosemide
• Paracentesis (ascitic tap or ascitic drain)
• Prophylactic antibiotics against spontaneous bacterial peritonitis (ciprofloxacin or norfloxacin) in patients with less than 15g/litre of protein in the ascitic fluid
• Consider TIPS procedure in refractory ascites
• Consider transplantation in refractory ascites

Question 18

Describe the different grades in Hepatic Encephalopathy?

Answer 18

• Grade 1
  
  • Psychomotor slowing
  • Constructional apraxia
  • Poor memory
  • reversed sleep pattern
• Grade 2
  
  • Lethargy
  • Disorientation
  • Agitation/irritability
  • Asterixis
• Grade 3
  
  • Drowsy
• Grade 4
  
  • Coma

Question 19

How would you mx gastrointestinal bleeding?

Answer 19

• Primary prophylaxis: propranolol, carvedilol
• Acute variceal haemorrhage: Medical emergency, ABCDE management, endoscopic variceal band ligation.
• Secondary prophylaxis: After the management of an acute bleed patients should be offered enter a banding surveillance programme and offered a non-selective beta blockers (i.e. propranolol, carvedilol),

Question 20

What is the Px of Gastrointestinal bleeding?

Answer 20

1. Cirrhosis leads to portal hypertension
2. Blood is shunted into the systemic circulation at porto-systemic sites
3. At the lower oesophagus this leads to dilated, tortuous vessels known as varices that are at high-risk of bleeding

Question 21

Which pt are at risk of developing hepatocellular carcinoma?

Answer 21

• cirrhosis
• chronic hepatitis B

Question 22

What is the screening programme for Hepatocellular carcinoma?

Answer 22

• six monthly surveillance with ultrasound +/- AFP
• for high risk pt

Question 23

What are the two types of hepatorenal syndrome?

Answer 23

Type 1 HRS

• Rapidly progressive
• Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
• Very poor prognosis

Type 2 HRS

• Slowly progressive
  Prognosis poor, but patients may live for longer