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Presentation of Basic Medical Information and Management of Cirrhosis of the Liver


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good presentation. my borther is diagnosed with Cirrhosis last week. how long his life will be. and i need copy of your slides.

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good presentation

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what a great and informatives slide.... can i download this. thanks

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Presentation Transcript

Cirrhosis : 

Cirrhosis Ryan Ford MD February 19, 2003

Cirrhosis : 

Cirrhosis Definition: Fibrosis of the liver with the formation of regenerative nodules. Number 10 of the top 10 reasons people depart the Earth. 1.2% of all deaths and 1% of hospitalizations are due to cirrhosis and complications thereof. Prevalence is on the rise.

Pathophysiology : 

Pathophysiology Cirrhosis is the final common pathway of chronic liver injury. Fibrous scar tissue replaces viable hepatocytes. Fibrosis leads to increasing resistance to blood flow through the liver. Ascites, Portal Hypertension, Hemorrhoids, Esophageal varices.

Gross PathologyHealthy Liver : 

Gross PathologyHealthy Liver

Gross PathologyCirrhosis : 

Gross PathologyCirrhosis

Gross Pathology Cirrhosis : 

Gross Pathology Cirrhosis

Causes of Cirrhosis : 

Causes of Cirrhosis Common Causes (>80% of all cases): Hepatitis C Alcoholism Obesity Other Causes: Hepatitis B Primary Biliary Cirrhosis Primary Sclerosisng Cholangitis Hemochromatosis Wilson’s Disease Alpha-1 Antitrypsin

Classification of Cirrhosis : 

Classification of Cirrhosis Child-Pugh

Child-Pugh Interpretation : 

Child-Pugh Interpretation Class A patients (5-7 points): Good life expectancy, good candidates for transplantation. Class B patients (8-10 points): Require frequent medical attention/hospitalization and have a statistically shortened life expectancy. Class C patients (11-15 points): Often ICU patients

Cirrhosis Evaluation : 

Cirrhosis Evaluation History With careful attention to Social History Use of I.V. drugs, alcohol use, etc. Physical Skin: Jaundice, Spider Angiomas, palmar erythema, caput medusae. Nails: White nails, clubbing Other: Splenomegaly, ascites, testicular atrophy, gynecomastia, muscle wasting.

Skin Findings : 

Skin Findings

Skin Findings : 

Skin Findings

Cirrhosis Evaluation : 

Cirrhosis Evaluation Labs: CBC, CMP, PT/INR, Hepatitis Panel If you suspect encephalopathy… Ammonia If you suspect hemachromatosis… iron panel If you suspect autoimmune… ANA, AmtA, and anti-smooth muscle antibodies. If you suspect Wilson’s… Ceruloplasmin If you suspect alpha-1 antitrypsin… Alpha-1 Antitrypsin Level Screen for hepatocellular carcinoma with AFP every 6 months.

Cirrhosis Evaluation : 

Cirrhosis Evaluation Imaging Ultrasound: Fast and cheap, good for detection cirrhosis, ascites, and other pathology. CT: Benefit really doesn’t outweigh cost when compared to ultrasound MRI: Generally reserved for evaluation of potential tumors within the liver.

Cirrhosis Evaluation : 

Cirrhosis Evaluation Liver Biopsy: Indications: Need for tissue diagnosis Contraindicaions: Coagulopathy or ascites, Endoscopy: EGD: For screening for esophageal varices. Colonoscopy: Indicated as evaluation of potential transplant candidates.

Cirrhosis Treatment : 

Cirrhosis Treatment Prevent further liver injury Hepatitis A & B immunization Cessation of alcohol Weight loss Treat the cause of Cirrhosis Hemochromatosis, alcoholism, wilson’s etc. Treat the Complications of Cirrhosis

Cirrhosis Treatment : 

Cirrhosis Treatment Do no Harm: Avoid sedatives, narcotics, constipating and nephrotoxic drugs. Avoid elective surgery Vaccinate to Hepatitis A & B Educate: No alcohol Encourage weight loss No NSAID’s No lifting >40 lbs. (Valsalva)

Ascites : 

Ascites The presence of ascites predicts a 50% mortality within 2 years. The cycle: Passive congestion leads to portal hypertension which further produces ascitic fluid. As systemic volume falls the kidneys hold on to sodium, water follows (hypervolemia) and the cycle continues. Prevention involves: Sodium restriction to 2g/day Diuretic use

Ascites Treatment : 

Ascites Treatment Drugs: Spironolactone, Loop diuretics, K-Sparing diuretics. Paracentesis: Indicated for tense ascites despite maximal diuretic use. Large Volume Paracentesis (LVP) can be performed in an outpatient setting up to every 2 weeks.

Ascites Treatment : 

Ascites Treatment Peritoneovenous Shunts (PVSs): Creates a one way bypass from the peritoneum to the superior vena cava. Plagued by obstruction, infection and other problems. Transjugular intrahepatic portasystemic shunt (TIPS): Reduces ascites but greatly increases the risk of development of encephalopathy.

Spontaneous Bacterial Peritonitis (SBP) : 

Spontaneous Bacterial Peritonitis (SBP) Bacterial infection of ascitic fluid. Typically gut flora (E. Coli, Klebsiella, Strep) Treatment Cefotaxime 2g IV q8h x five days Spectrum narrowing based on culture results. Diagnosis >250 PMN’s on high power field + Bacterial growth on culture Absence of Surgically treatable source of infection.

Hepatic Encephalopathy : 

Hepatic Encephalopathy Caused by absorption of toxins from the gut and the shunting of these sedating toxins past the liver to the brain.

Trail Test : 

Trail Test

Hepatic Encephalopathy : 

Hepatic Encephalopathy Treatment: Lactulose Grade 0-2: Treat with oral Lactulose 30ml p.o. bid – qid as needed to have 2-3 loose stools daily. Grade 3-4: If too somnolent or comatose to have an NGT or P.O. meds Dr. Kumar Special: 300ml of lactulose with 700ml of tap water PR q 4-8h until pt. Is alert enough to resume oral diet.

MOA of Lactulose Therapy : 

MOA of Lactulose Therapy Decrease production of ammonia and other toxins by intestinal flora. Ioninic trapping (by lowering intestinal pH) and subsequent elimination. Decreased colonic transport time (decreases absorption opportunity)

Hepatic Encephalopathy : 

Hepatic Encephalopathy Additional Therapy: For patients refractory to lactulose addition of neomycin may be beneficial. 500 – 1000 mg bid Watch for potential ototoxicity/nephrotoxicity. For patients refractory to both lactulose and neomycin… Low protein diet.

Variceal Bleeding : 

Variceal Bleeding Potentially fatal complication with massive GI hemorrhage. Requires initial stabilization with IV fluids and blood. NGT with Gastric lavage in preparation for EGD with banding Balloon tamponade for bleeding which obscures view by Endoscopy.

Esophageal Varices : 

Esophageal Varices

Prevention of Variceal Rebleeding : 

Prevention of Variceal Rebleeding Avoid NSAIDs Completely Beta-Blockers Porto-systemic shunts

References : 

References Robbins, Stanley L., Pathologic Basis of Disease, 1994, 5th edition. White, Gary M., Diseases of the Skin, 2000, 1st edition. Goodman, Joel G. et al., The Pharmocological Basis of Therapeutics, 1996, 9th edition. MD Consult WebPATH at University of Utah

Questions??? : 

Questions??? Questions?

I’d rather be here right now. : 

I’d rather be here right now.

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