dr allister j grant consultant hepatologist university hospitals leicester nhs trust
DESCRIPTION
Dr Allister J Grant Consultant Hepatologist University Hospitals Leicester NHS Trust. Anatomy &Physiology. Anatomy &Physiology. IVC. Portal Vein. Hepatic Artery. Splenic Vein. CBD. Gallbladder. SMV. Anatomy &Physiology. Anatomy &Physiology. Liver Functions. Nutrition/Metabolic - PowerPoint PPT PresentationTRANSCRIPT
Dr Allister J GrantConsultant Hepatologist
University Hospitals Leicester NHS Trust
Anatomy &Physiology
Anatomy &Physiology
Anatomy &Physiology
Hepatic Artery
IVC
Splenic Vein
SMVGallbladder
Portal Vein
CBD
Anatomy &Physiology
Liver Functions
Nutrition/Metabolic– stores glycogen (glucose chains)– releases glucose when if no insulin– absorbs fats, fat soluble vitamins– manufactures cholesterol
Bile Salts– lipids derived from cholesterol– dissolves dietary fats (detergent)
Bilirubin– breakdown product of haemoglobin
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
Symptoms
Early disease• asymptomatic• fatigue, malaise• anorexia, nausea• jaundice• pruritis• easy bruising and
bleeding• abdominal pain
Cholestatic patients• fatigue, malaise• anorexia, nausea• jaundice• +++ pruritis• +++ grey or clay-
coloured stools
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
Disease ProgressionL
iver
fu
nct
ion
100%
Cirrhosis
Liver Failure
Years
A
B
C
Causes of Chronic Liver disease
• Viral• Hepatitis B• Hepatitis C
• Autoimmune Hepatitis
• Metabolic• NASH• Amyloid
• Alcoholic Cirrhosis
• Inherited• Haemochromatosis• Wilsons Disease -1 Antitrypsin Deficiency
• Biliary Disease• PBC• PSC• Secondary sclerosing
cholangitis• Caroli’s syndrome
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
Cirrhosis
Expanded Portal Tracts(Blue)
Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
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)
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
Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
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
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
DECREASED HEPATOCELLULAR FUNCTION
– Worsened intrinsic liver disease– Hypoxia – Anaemia – Development of hepatocellular carcinoma – Dehydration – Hypotension – Sepsis– Drug toxicity – Superimposed viral hepatitis
Causes of Encephalopathy
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
Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
Portal Circulation
Oesophageal varices
Prognosis
1 Year Survival
– Child Pugh A 80 - 100%
– Child Pugh B 60 - 80%
– Child Pugh C 35 - 45%
Management of Bleeding Varices
• Prevention
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
Management of Bleeding Varices
• Prevention
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
Fluid Management
• Crystalloid
• Colloid
• Blood
• Platelets
• FFP
• Vitamin K
Management of Bleeding Varices
• Prevention
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
Oesophageal varices
Oesophageal varices
Bleeding Gastric Varices
Variceal Bander
Variceal Band Ligation
Management of Bleeding Varices
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
PharmacotherapyTerlipressin vs. Balloon Tamponade
Mortality
Terlipressin vs. Endoscopic TherapyMortality
Favours Terlipressin Favours Tamponade
Management of Bleeding Varices
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
Sengstaken-Blakemore Tube
Complication of SBT
Management of Bleeding Varices
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
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!