Common Fungal Infections

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CIRRHOSIS OF LIVER:

CIRRHOSIS OF LIVER

DEFINITION:

DEFINITION Chronic generalised liver disease Necrosis of liver cells Regeneration Loss of architecture Fibrosis Nodule formation – Macronodular and micronodular

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Normal Micronodular Macronodular

Epidemiology:

Epidemiology 40% cases asymptomatic Chance discovery Around 350/100,000 population Approximately 30,000 to 50,000 deaths per year Additional 10,000 deaths due to liver cancer secondary to cirrhosis

Etiology:

Etiology Chronic alcoholism Viral hepatitis B,C,D Autoimmune hepatitis Drugs or toxins – amiodarone, methotrexate, Vitamin A, CCL 4 Metabolic disorders- Wilsons disease Haemochromatosis Alpha1 antitrypsin defeciency Glycogen storage disorder

Etiology Contd….:

Etiology Contd…. Nonalcoholic steatohepatitis (NASH) Vascular derangement - Chronic right heart failure, Budd chiari syndrome Biliary disorders – primary biliary cirrhosis, cystic fibrosis, sarcoidosis, chronic large bile duct obstruction Malnutrition CRYPTOGENIC

Clinical features:

Clinical features A – Anaemia, Angioma (Spider), Atrophy of testis, Asterexis, Ascites, Absence of axillary and pubic hair Alopecia Atrophy of breast in females Apraxia (constructional)

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Asterexis Spider

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B Bleeding tendency – defeciency of coasgulation factors CHECK PT INR C Clubbing Colour of Nails (white – leuconychia) Caput medusae Cyanosis

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D Delirium Dupuytren’s contracture E Edema Erythema of palms Encephalopathy

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F Fetor hepaticus ( methyl mercaptan) Fever Flapping tremor G Gynecomastia H Hyperdynamic circulatory state Hyperpigmentation

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I Icterus Inversion of sleep rhythm J JAUNDICE

SEQUELAE OF CIRRHOSIS:

SEQUELAE OF CIRRHOSIS CONSEQUENCES OF HEPATIC SYNTHETIC FAILURE : Hypoalbuminamia Coagulopathy Jaundice Susceptibility to infection Renal dysfunction

SEQUELAE OF CIRRHOSIS Contd….:

SEQUELAE OF CIRRHOSIS Contd…. CONSEQUENCES OF HEPATIC SYNTHETIC FAILURE Contd.. Cholilithiasis Pruritis Altered drug metabolism Hepatic osteodystrophy Gonadal failure

SEQUELAE OF CIRRHOSIS Contd…:

SEQUELAE OF CIRRHOSIS Contd… CONSEQUENCES OF PORTAL HYPERTENSION Splenomegaly with hypersplenism Gastrointestinal bleeding – oesophageal/ gastric varices Portal gastropathy Ascites – SBP , Hydrothorax, Hernias

SEQUELAE OF CIRRHOSIS Contd…:

SEQUELAE OF CIRRHOSIS Contd… CONSEQUENCES OF PORTAL HYPERTENSION Contd… Hepatorenal syndrome Hepatopulmonary syndrome Hepatic encephalopathy

SEQUELAE OF CIRRHOSIS contd …:

SEQUELAE OF CIRRHOSIS contd … HEPATOCELLULAR CARCINOMA

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HCC – cirrhotic liver HCC

:

HYPOALBUMINAEMIA – Reduced plasma oncotic pressure – edema ascites COAGULAOPATHY – all clotting factors except factor VIII synthesised by liver Thrombocytopenia due to hypersplenism DIC with sepsis(assay factor VIII level decreased only in DIC) JAUNDICE – failure of conjugation and excretion , both indirect and direct hyperbilirubinemia

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PROTEIN CALORIE MALNUTRITION Anorexia , nausea , Ascites with abdominal distension , Intestinal edema, diarrhoea, decreased bile flow, Reduced hepatic stores of water soluble vitamins and trace elements, Impaired glucose tolerance, diabetes

Susceptible to infection :

Susceptible to infection Facultative gram negative bacteremia, Tuberculosis Hypoalbuminemia, ascites and gut edema Impaired functioning of reticuloendothelial system Hypersplenism – leucopenia,thrombocytopenia ( infection without fever and leucocytosis ) Decreased serum opsonic activity Phagocytic and bacterial killing capacity of neutrophills impaired

Hypersplenism :

Hypersplenism

RENAL DYSFUNCTION:

RENAL DYSFUNCTION Diminished ability to excrete sodium load – fluid retention,ascites,dilutional hyponatriemia Renin angiotensin aldosterone axis stimulated Renal perfusion GFR decreased Increase in levels of ADH Circulating Blood volume decreased

DIAGNOSIS & INVESTIGATIONS:

DIAGNOSIS & INVESTIGATIONS Complete Hemogram Peripheral Smear Platelet Count PT INR LFT – S. Bilirubin, S. Albumin, S. Globulin, SGPT, SGOT, ALP Hepatitis Profile Alpha Fetoprotein

Investigations Contd…:

Investigations Contd… Blood sugar Urea, Creatinine Sodium, Potassium X-Ray chest USG / CT Abdomen Confirmation by Liver Biopsy

MAJOR COMPLICATIONS:

MAJOR COMPLICATIONS PORTAL HYPERTENSION > 15 mmHg Cirrhosis – Sinusoidal Pre-sinusoidal - Extra Hepatic Intra Hepatic Post sinusoidal – Intra Hepatic Extra Hepatic

CLINICAL FEATURES OF PORTAL HYPERTENSION:

CLINICAL FEATURES OF PORTAL HYPERTENSION Splenomegaly – Hypersplenism – Thrombocytopenia, Neutropenia, Anemia Dilated Abdominal Veins, Caput Medusae, Ascitis Oesophageal varices

VARICEAL HEMORRHAGE:

VARICEAL HEMORRHAGE Oesophageal varices / Gastric varices MASSIVE HEMATEMESIS / MELENA PAINLESS Precipitating Factors – Alcohol, Aspirin, Analgesics (NSAIDs), Adrenal Corticosteroids Assessment – Drop in systolic BP > 10 mmHg, rise in pulse > 15 beats / minute on sitting up – 10 to 20% Supine Hypotension - > 20% Systolic BP < 100 mmHg / Baseline Tachycardia > 25%

RESUSCITATION :

RESUSCITATION Stabilize BP – 2 large bore IV line – 14 to 18 Isotonic saline / Ringer Lactate / fresh blood / packed RBC transfusion – Maintain ½ hour pulse, BP, respiration chart (In emergency situation – O-ve blood) MEASURE URINE OUTPUT Correction of coagulopathy – FFP, parenteral Vit K 10 mg SC / IM Platelet transfusion – if count < 50,000 Airway protection – endotracheal intubation to prevent aspiration

RESUSCITATION:

RESUSCITATION Nasal Gastric Aspiration OCTREOTIDE Infusion 50 to 100 µgm bolus 25 to 50 µgm / hour infusion VASOPRESSIN 0.3 unit / minute IV – gradually increased to 0.9 units/minute – Myocardial ischemia, infarction, arrhythmia, cardiac arrest, mesenteric ischemia -

RESUSCITATION:

RESUSCITATION Nitro Glycerin – if systolic BP > 100 mmHg, 10 µgm/minute IV until systolic BP falls to 100 mmHg OGD – Variceal ligation or banding Sclerotherapy Transjugular intra hepatic portosystemic shunt - TIPS

RESUSCITATION:

RESUSCITATION Shunt surgery Balloon tamponade – Sengstaken Blakemore tube Prophylaxis – Propranolol – resting Heart Rate to be reduced by 25%

ASCITES:

ASCITES 50% of patients die within 2 years Hypoalbuminemia – decreased oncotic pressure Renin angiotensin, Aldosterone axis Increased lymphatic exudation S. Ascites, Albumin gradiant – SAAG > 1.1 gm /dl – portal hypertension < 1.1 gm/dl – Neoplasm, TB, Pancreatitis, Bile leak Amylase, Cytology, AFB culture

ASCITES:

ASCITES Dietary sodium restriction – 2gm/day Spironolactone 50 to 100 mg/day – maximum 400 mg (0.5 to 0.75 Kg weight loss/day) Furosemide 40 to 80 mg Paracentesis – diagnostic , therapeutic – 4 to 6 Litres (infused 6 to 8 gm albumin /Litre of ascites removed).

ASCITES - SBP:

ASCITES - SBP Spontaneous Bacterial Peritonitis E.coli, Pneumococcus, Klebsiella PMN count > 250 cmm 3 Cefotaxime 1 to 2 gm IV 6 to 8 hours Ceftriaxone 500 to 1000 mg IV 12 hours Norfloxacin 400 mg/day

HEPATIC ENCEPHALOPATHY:

HEPATIC ENCEPHALOPATHY Precipitating factors GI Bleeding Excess protein intake Electrolyte abnormalities, Ascitic Aspiration Uremia Dehydration, Constipation Alcohol Viral infections, SBP Anaesthetic agents, Surgery, Narcotics, Tranquilisers Hepatic toxins, Portosystemic shunts - TIPS

HEPATIC ENCEPHALOPATHY:

HEPATIC ENCEPHALOPATHY Hyperammonemia – Blocks Citric acid cycle Treatment–CORRECT/ AVOID PRECIPITATING FACTORS Dietary protein restriction-30 - 40 gm protein / day Non absorbable disaccharide – LACTULOSE – 15 to 45 ml BID / QID Lactulose enema Neomycin 1 gm 6 th hrly Metronidazole 250 mg 8 th hrly Bowel wash / Lactobacillus

GRADING OF HEPATIC ENCEPHALOPATHY:

GRADING OF HEPATIC ENCEPHALOPATHY 0 – Normal 1 – Inverted sleep rhythm, restless 2 – Lethargy, slow response 3 – Drowsy, arousable but confused 4 - Coma

HEPATOPULMONARY SYNDROME:

HEPATOPULMONARY SYNDROME Dyspnoea on standing position – PLATYPNEA Hypoxia in standing position-ORTHODEOXIA Intra Pulmonary Vascular dilatation in the absence of intrinsic cardio pulmonary disease

MALIGNANT TRANSFORMATION:

MALIGNANT TRANSFORMATION Rapid, unexplained weight loss Unexplained fever Pain in the right Hypochondrium Rapid enlargement of liver / one of the nodules Hepatic Rub / Hepatic Bruit Hemorrhagic ascitic fluid Malignant cells in cytology of Ascitic fluid Confirmation by USG / CT / AFP / Biopsy

PROGNOSIS CHILD - TURCOTTE – PUGH Scoring :

PROGNOSIS CHILD - TURCOTTE – PUGH Scoring Clinical and biochemical measurements Points scored for increasing abnormality 1 2 3 Albumin (g/dl) > 3.5 2.8 to 3.5 < 2.8 Bilirubin (mg/dl) 1 to 2 2 to 3 > 3 For cholestatic diseases : bilirubin (mg/dl) < 4 4 to 10 > 10 PT (secs prolonged)* Or INR* 1 to 4 4 to 6 > 6 < 1.7 1.7 to 2.3 > 2.3 Ascites Absent Slight Moderate Encephalopathy (grade) None 1 & 2 3 & 4

CTP SCORING SYSTEM:

CTP SCORING SYSTEM Class A – 5 to 6 points Class B – 7 to 9 points Class C – 10 to 15 points B & C – Potential candidates for Hepatic transplantation

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