dr allister j grant consultant hepatologist university hospitals leicester nhs trust
DESCRIPTION
Dr Allister J Grant Consultant Hepatologist University Hospitals Leicester NHS Trust. IVC. Portal Vein. Hepatic Artery. Splenic Vein. CBD. Gallbladder. SMV. Anatomy &Physiology. Anatomy &Physiology. Liver Functions. Nutrition/Metabolic – stores glycogen (glucose chains) - PowerPoint PPT PresentationTRANSCRIPT
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Dr Allister J GrantConsultant Hepatologist
University Hospitals Leicester NHS Trust
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Anatomy &Physiology
Hepatic Artery
IVC
Splenic Vein
SMVGallbladder
Portal Vein
CBD
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Anatomy &Physiology
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Liver Functions
Nutrition/Metabolic– stores glycogen (glucose chains)– releases glucose– absorbs fats, fat soluble vitamins– manufactures cholesterol
Bile Salts– lipids derived from cholesterol– dissolves dietary fats (detergent)
Bilirubin– breakdown product of haemoglobin
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Liver Functions
Clotting Factors– manufactures most clotting factors
Immune function– Kupfer cells engulf antigens (bacteria)
Detoxification– drug excretion (sometimes activation)– alcohol breakdown
Manufactures Proteins– albumin– binding proteins
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Disease Progression
Acute Liver Failure
• <6 weeks duration
• Jaundice• Encephalopathy• Cerebral Oedema• Acute Renal Failure• Acidosis• Hypoglycaemia• MOF
Chronic Liver Disease
• >6 months
Cirrhosis leading to
• Recurrent decompensation– Ascites– Portal Hypertension (variceal
bleeding)– Encephalopathy
• Low albumin/Malnutrition• Hepatorenal syndrome• Hyponatraemia• Hepatoma
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Disease ProgressionL
iver
fu
nct
ion
100%
Cirrhosis
Liver Failure
Years
A
B
CD
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24♀ 48hours post POD
• ALT 13000• Alb 35• Bili 40
• Cr 160• Urea 24
• INR 3.0• PT 33
• Glc 3.6
• Ph 7.1
• PCO2 3.2
• PO2 12.4
• BE -6
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ALF
• Treat the underlying cause• Resuscitate - Central access early • Give N-Ac regardless of cause• Monitor for hypoglycaemia• Monitor coagulopathy• Antibiotic prophylaxis• Stress Ulcers• Early elective ventilation for encephalopathy• Nutrition• Acidosis/ Renal Impairment
• Early referral to Hepatology / discuss with Birmingham Liver Unit
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Mrs W
• 48 year old ♀ admitted from a surgical clinic with jaundice and unwell
• Unwell for 6 wks after holiday in Mexico
• Hx of xs alcohol 30u/wk
• No previous jaundice
• USS normal size liver and spleen – biliary tree normal
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OE
• Jaundice• Drowsy• Agitated/Irritable• Doesn’t obey
commands• No stigmata of CLD• Asterixis
No spleenNo ascites
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Mrs W
• U&E normal
• ALP 107• ALT 736• Bili 363• Alb 24
• FBC Normal
• INR 3.7
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Causes of Acute Liver Failure
• Drugs• Paracetamol (UK)• INH• Halothane• Ecstacy
• Viral• Hepatitis A• Hepatitis B• Hepatitis E• Non-A Non-B
• Wilsons Disease
• Autoimmune Hepatitis
• Reye’s Syndrome
• Cardiovascular• Ischaemic hepatitis• Budd Chiari
• Acute Fatty Liver of Pregnancy
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Encephalopathy
• Grade 1» Constructional apraxia» Poor memory – number connection test» Agitation/ irritability» Reversed sleep pattern
• Grade 2» Lethargy, disorientation» Asterixis
• Grade 3» Drowsy, reduced conscious level
• Grade 4» Coma
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Cirrhosis
Expanded Portal Tracts(Blue)
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Signs of Chronic Liver Disease
• None• Asterixis/Flap• Relative hypotension• Oedema• Jaundice/No jaundice• Large/Small liver• Splenomegaly• Gynecomastia• Testicular atrophy-loss of secondary sexual
characteristics• Impotence
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Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
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Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
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The Development of Ascites
50% of compensated cirrhotics develop ascites over 10yrs
50% of cirrhotics with ascites will die within 2 yrs
(50% 2yr rule for OLTx assessment)
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The Development of Ascites
Peripheral arterial dilatation
Reduced effective blood volume
Activation of renin-angiotensin-aldosterone systemSympathetic nervous systemADH
Na retention &Water retention
Low urinary NaDilutional hyponatraemia
AscitesSchrier et al Hepatol 1988
Plasma volume expansion
NaCl
Ascites and Oedema
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General Management
Ascites and Oedema
• Salt restriction
• Diureticsspironolactonefrusemide
• Water restriction if sodium < 125 mmol
• Paracentesisdiagnostic (SBP, tumour)therapeutic (20% Alb)
• DAILY WEIGHTS!
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Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
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Causes of EncephalopathyINCREASED AMMONIAGENESIS
Increased substrate (protein) for ammoniagenesis
– Increased protein intake– Gastrointestinal bleeding– Constipation– Dehydration
Increased substrate (urea) for ammoniagenesis
– Renal failure
Increased catabolism of protein
– Infection– Hypokalemia– Sepsis
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DECREASED HEPATOCELLULAR FUNCTION
– Worsened intrinsic liver disease– Hypoxia – Anaemia – Development of hepatocellular carcinoma – Dehydration – Hypotension – Sepsis– Drug toxicity – Superimposed viral hepatitis
Causes of Encephalopathy
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INCREASED PORTOCAVAL SHUNTING
– Portal vein thrombosis – Transjugular intrahepatic portosystemic shunt formation – Surgical shunt formation – Spontaneous shunt formation
PSYCHOACTIVE DRUG USE
– Benzodiazepines – Ethanol – Antiemetics– Antihistamines – Others
Causes of Encephalopathy
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General ManagementEncephalopathy
Minimize effects of liver disease
Treat precipitants• sepsis• GI bleed• medications (over-diuresis)
Avoid sedatives, hypnotics, opiates
Lactulose to ensure BO 2x/day
Metronidazole/ neomycin
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Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
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Oesophageal varices
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Management of Bleeding Varices
• Prevention
• Prophylactic Antibiotics
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
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Management of Bleeding Varices
• Prevention
• Prophylactic Antibiotics
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
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Fluid Management
• Crystalloid
• Colloid
• Blood
• Platelets
• FFP
• Vitamin K
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Management of Bleeding Varices
• Prevention
• Prophylactic Antibiotics
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
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Oesophageal varices
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Bleeding Gastric Varices
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Variceal Bander
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Variceal Band Ligation
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Management of Bleeding Varices
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin 2mg qds i.v
• Balloon Tamponade
• TIPS
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Management of Bleeding Varices
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
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Sengstaken-Blakemore Tube
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Complication of SBT
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Management of Bleeding Varices
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
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The End“All right, let's not panic.
I'll make the money by selling one of my livers.I can get by with one “
Doh!