management of liver cirrhosis

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  • 1. MANAGEMENT OF LIVERCIRRHOSISBy ANNOY MALLICK9TH SEMESTERGuided by: Dr. N. K. SundarayDr. S.K. Barad

2. Cirrhosis is a consequence of chronic liver disease characterised by:- replacement of liver tissue by fibrous scar tissue as well as regenerative nodules(lumps that occur as a result of a process in which damaged tissue is regenerated).- leading to progressive loss of liver function. 3. Manifestations of Liver Cirrhosis 4. PREVENTION Eliminating alcohol abuse could prevent 7580% of all cases of cirrhosis. Maintaining a healthy diet that includes whole foods and grains, vegetable, andfruits. Obtaining counseling or other treatment for alcoholism. Taking precautions (practicing safe sex, avoiding dirty needles) to prevent hepatitis. Getting immunizations against hepatitis(A and B), pneumococcus and influenza if aperson is in a high-risk group . receiving appropriate medical treatment quickly when diagnosed with hepatitis B orhepatitis C. Having blood drawn at regular intervals to rid the body of excess iron fromhemochromatosis. Wearing protective clothing and following product directions when using toxicchemicals at work, at home, or in the garden. 5. GUIDELINES FOR MANAGEMENTThe major goals of treating the cirrhotic patient include:1. Slowing or reversing the progression of liver disease2. Preventing superimposed insults to the liver3. Preventing and treating the complications4. Determining the appropriateness and optimal timing for livertransplantation 6. MANAGEMENTThere is no specific drug therapy for cirrhosisDrugs are used to treat symptoms and complications of advanced liver disease1. General management2. Specific treatments3. Treatment of complications of cirrhosis4. liver transplantation 7. 1. GENERAL MANAGEMENT Good nutrition Low salt diet Alcohol abstinence Avoid NSAID and sedatives & opiates Cholestyramine for pruritus Avoiding hepatotoxic drugs 8. 2. SPECIFIC MANAGEMENT 9. AETIOLOGY OF CIRRHOSIS Alcoholic cirrhosis Post viral cirrhosis( Hepatitis B, Hepatitis C and Hepatitis B+D) Drug induced cirrhosis Biliary cirrhosis NASH Chronic autoimmune hepatitis Hemochromatosis Wilsons disease Alpha1- antitrypsin deficiency Hepatic outflow tract obstruction Idiopathic cirrhosis 10. TREATMENT BASED ON AETIOLOGY Alcoholic cirrhosis-1. Complete abstinence from alcohol2. Nutritional support(>3000kcal/day) along with multivitamins3. Prednisolone and Pentoxifylline in severe cases Post viral cirrhosis-1. For chronic hepatitis B infection, Interferon alpha-2b (5 million units daily s.c. or 10million units thrice a week for 4-6 months) or pegylated Interferon alpha-2b once in aweek ; lamivudine 100mg once daily until HBeAg becomes negative ; entecavir,tenofovir, adefovir dipivoxil or telbivudine can also be tried.2. Patients with chronic hepatitis C infection must receive pegylated Interferon alpha-2band ribavirin.3. In a case of both hepatitis B and D co-infection, pegylated Interferon alpha-2b has beenfound effective. Drug induced cirrhosis- methotrexate, methyldopa, isoniazid, phenylbutazone,sulphonamides 11. TREATMENT BASED ON AETIOLOGY contd. Biliary cirrhosis-1. Ursodeoxycholic acid(10-15mg/kg)2. Steroids3. Azathioprine, colchicine, methotrexate or cyclosporine4. Limit fat intake5. Monthly injections of vitamin K NASH-1. Control of weight, Diabetes and hyperlipidemia2. Metformin, pioglitazone, UDCA, pentoxyfylline and atorvastatin might be helpful Hemochromatosis-1. Weekly venesection of 500ml of blood until serum iron is normal2. Chelation therapy with desferrioxamine(40-80mg/kg/day)3. Treatment for diabetes, CHF. 12. TREATMENT BASED ON AETIOLOGY contd. Wilsons disease-1. Chelating agents like penicillamine(1g/day) or trientine hydrochloride(1.2-2.4g/day),Zinc acetate can be added to the therapy2. Patients with neurologic involvement can be given dimercaprol i.m. ortetrathiomolybdate3. Liver transplantation in advanced cases Hepatic outflow tract obstruction-1. Predisposing causes should treated2. TIPSS for opening hepatic veins3. Streptokinase followed by heparin and warfarin in case of thrombosis4. Percutaneous balloon angioplasty5. Liver transplantation in advanced cases 13. 3. MANAGEMENT OF COMPLICATIONS 14. MAJOR COMPLICATIONS1. Ascites2. Spontaneous bacterial peritonitis3. Hepatic encephalopathy4. Portal hypertension5. Variceal bleeding6. Renal failure7. Portal vein thrombosis8. Hepatocellular carcinoma9. Hemorrhagic manifestations 15. MANAGEMENT OF COMPLICATIONSAscites- bed rest low salt diet (4-6g of salt) avoid NSAIDs fluid restriction to 1-1.5L/24 hr spironolactone 25mg/6 hr orally and increase dose every 48 hr to 400mg/24hr; triamterene andamiloride can also be tried. Frusemide can be added to the above therapy daily weight chart weight loss 5cm or no more than 3 lesions with the largestbeing less than equal to 3cm Alcoholic cirrhosis Cirrhosis due to hepatitis C Alpha1Antitrypsin deficiency Glycogen storage disorder 21. SIGNS OF LIVER INSUFFIENCY POINTING TO THENEED FOR LIVER TRANSPLANT Sustained or increased jaundice Ascites Hepatic encephalopathy not responding to medical therapy Hypoalbuminaemia 65yrs age 24. PROGNOSIS OF CIRRHOSIS Overall prognosis is poor25% survive 5 years from diagnosis If liver function is good,50% survive for 5 years25% upto 10 years 25. POOR PROGNOSTIC FACTORS Deteriorating liver function Falling albumin 20g/L Marked hyponatremia

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