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Complications of Liver

CirrhosisAyman Abdo

MD, AmBIM, FRCPC

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Objectives

1. Understand the basic mechanisms

of portal hypertension

2. Recognized the classicpresentations of portal hypertension

complications

3. Get an idea on the management ofthese complications

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What is Liver Cirrhosis?

Diffuse fibrosis of the liver with

nodule formation

Abnormal response of the liver toany chronic injury

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Causes of Cirrhosis1. Chronic viral hepatitis

2. Metabolic: hemochromatosis, Wilson dis,alfa-1-antitrypsin, NASH

3. Prolonged cholestasis (primary biliarycirrhosis, primary sclerosing cholangitis)

4. Autoimmune diseases (autoimmune

hepatitis)5. Drugs and toxins

6. Alcohol

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Anatomy of the portal venous system

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The Effect of The Liver Nodule

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Mechanism of Portal HTN

Cirrhosis

Resistance portal flow

MechanicalNodules DynamicNitric oxide

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Complications of Portal

Hypertension

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1. Varices

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Collaterals

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Varices

Esophagus

Gastric

Colo-rectal

Portal hypertensive gastropathy

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Varices

DiagnosisHistory : Hematemases, melena

Physical examination

Ultrasound abdomen

Endoscopy

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Varices

Management-GeneralABC

2 IV LinesType and cross match

Resuscitation

IVFBlood

Platelet transfusion (platelet

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Varices

Management-SpecificIV vasoconstrictors (Octreotide)

Endoscopic therapyBanding

Sclerotherapy

Shunting

Surgical

TIPS

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Variceal Banding

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Types of Shunts

TIPS (Transjugular intrahepaticportosystemic shunt)

Surgical shunt

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Varices

PreventionTreat underlying disease

Endoscopic banding protocol

B-blockers

Shunt surgery (only if nocirrhosis)

Liver transplantation

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2. Ascites

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Ascites

Definition: fluid in theperitonial cavity

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Mechanism of Ascites

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Causes of Ascites

1. Liver disease: cirrhosis

2. Right sided heart failure

3. Kidney disease (nephrotic syndrome)4. Low albumin (malnutrition, bowel loss)

5. Peritonial infection (TB)

6. Peritonial cancer

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PresentationHistory:

Increased abdominal girth

Increased wt

Physical exam:

Bulging flanks

Shifting dullness

Fluid wave

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DiagnosisPhysical examination

Ultrasound

Ascitic tap

WBC (>250 PMN: SBP)

RBC

SAAG (serum albumin to ascitic fluid

albumin gradient)

>11 mg/dl : portal hypertension

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Portal hypertension

or heart failure

Peritonial disease

or kidney disease

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Treatment-General

Treat the underlying disease

Salt restriction (

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Treatment-Resistant

Recurrent tapping

Peritoneal-venous shunt

TIPS

Liver transplantation

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Spontaneous Bacterial Peritonitis

Infection of ascitic fluid

Usually gram negative (E.Coli)

Presentation variableMortality is high

Dx: ascitic tap = PMN>250

Treatment : third generation

cephalosporin IV

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3. Hepatic

Encephalopathy

H ti

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Hepatic

EncephalopathyReversible decrease in

neurological function secondaryto liver disease

Acute: seen with acute liverfailure

Acute on chronic: established

cirrhosis

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Hepatic EncephalopathyMechanism

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Hepatic EncephalopathyClinical features

Reversal of sleep pattern

Disturbed consciousnessPersonality changes

Intellectual deterioration

Fetor hepaticus

Astrexis

Fluctuating

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Flapping Tremor

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Drawing Tests

H ti E h l th

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Hepatic EncephalopathyDiagnosis

Clinical (most important)

The drawing tests

EEG

CT/MRI may show cerebral atrophy

H ti E h l th

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Hepatic EncephalopathyExacerbating factors

H ti E h l th

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Hepatic EncephalopathyTreatment

Identify and treat precipitation factor

Treat underlying liver disease

Normal protein diet

Antibiotics (Neomycin, metronidazole)

LactoloseTransplantation

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4. Hepatorenal

Syndrome

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Hepatorenal Syndrome

Progressive renal failure

Type 1 : rapidly progressive, high

mortalityType 2: slower progression

R/O volume depletion secondary to

diuretics

IV vasoconstrictors

Liver transplantation

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Summary

1. Mechanical compression of blood flow

plus hemodynamic changes leads to

portal hypertension

2. Common complications of portal

hypertension are:

Collateral formation (Varices)

Ascites

Hepatic encephalopathy

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Summary

3. The most important step in variceal bleed

management is resuscitation

4. The most important step in management

of hepatic encephalopathy is the

identification of the precipitating factor