The document provides a comprehensive overview of liver cirrhosis, including its diagnosis through clinical, laboratory, radiological methods, and liver biopsy. It outlines treatment measures aimed at preventing disease progression, addressing specific causes, and managing complications, with detailed protocols for various etiologies such as alcoholic liver disease, viral hepatitis, and others. Additionally, it covers liver transplantation criteria, types, and potential complications associated with the procedure.
The document provides a comprehensive overview of liver cirrhosis, including its diagnosis through clinical, laboratory, radiological methods, and liver biopsy. It outlines treatment measures aimed at preventing disease progression, addressing specific causes, and managing complications, with detailed protocols for various etiologies such as alcoholic liver disease, viral hepatitis, and others. Additionally, it covers liver transplantation criteria, types, and potential complications associated with the procedure.
The document provides a comprehensive overview of liver cirrhosis, including its diagnosis through clinical, laboratory, radiological methods, and liver biopsy. It outlines treatment measures aimed at preventing disease progression, addressing specific causes, and managing complications, with detailed protocols for various etiologies such as alcoholic liver disease, viral hepatitis, and others. Additionally, it covers liver transplantation criteria, types, and potential complications associated with the procedure.
The document provides a comprehensive overview of liver cirrhosis, including its diagnosis through clinical, laboratory, radiological methods, and liver biopsy. It outlines treatment measures aimed at preventing disease progression, addressing specific causes, and managing complications, with detailed protocols for various etiologies such as alcoholic liver disease, viral hepatitis, and others. Additionally, it covers liver transplantation criteria, types, and potential complications associated with the procedure.
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MANAGEMENT OF
LIVER CIRRHOSIS
Presenting by : Dr.Nagashree K P Guided by:Dr.Srinivas J Coordinated by: Dr.Anand Chavan DIAGNOSIS OF LIVER CIRRHOSIS
• CLINICAL • LABORATORY • RADIOLOGICAL • LIVER BIOPSY CLINICAL DIAGNOSIS Any patient with chronic liver disease • Symptoms like vague abdominal pain/discomfort,fatigue, jaundice, nausea, vomiting,etc • Stigmata of chronic liver disease (muscle wasting, vascular spiders, palmar erythema) • Palpable left lobe of the liver • Small liver span • Splenomegaly • Signs of decompensation (jaundice, ascites, asterixis) • Chronic abnormal aminotransferases and/or alkaline phosphatase LIVER FUNCTION TESTS LABORATORY DIAGNOSIS • Liver insufficiency Low albumin (< 3.8 g/dL) Prolonged prothrombin time (INR > 1.3) High bilirubin (> 1.5 mg/dL) Low platelet count (< 175 x1000/μl) AST/ALT ratio > 2 Radiological investigations • USG abdomen • CT scan • MRI LIVER BIOPSY • Commonly performed to help diagnosis ,assessment of the severity and staging of liver damage, prediction of prognosis and monitoring of response to treatment. • Indications -abnormal liver test result that can’t be explained -a mass or other abnormalities on liver as seen on imaging test TREATMENT OF LIVER CIRRHOSIS 1 MEASURES TO PREVENT FURTHER PROGRESSION
• Consumption of balanced diet and one multivitamin daily
• Abstinence from alcohol • Avoidance of hepatotoxic drugs including NSAIDS • Sodium(2g/day) and water restriction • Glucocorticoids • Immunization 2 TREATMENT OF CIRRHOSIS SPECIFIC CAUSE. DRUGS 1. Alcoholic. * Alcohol abstinence Prednisone 40mg/Pentoxyfylline 400mg tid 2. Hep B * Entecavir 0.5mg/Tenofovir 300mg daily 3. Hep C. * velpatasavir 100mg+Sofosbuvir 400mg daily Ribavarin added in decompensated cirrhosis 4. Wilson’s. * D-penicillamine500mg tid+pyridoxine Trientine+zinc 5. Hemochromatosis. * Desferrioxamine sc 6. Biliary cirrhosis. * UDCA 7. NASH. * Vit .E (doc)800-1000 IU/day pioglitazone/Pentoxyfylline 3.TREATMENT OF COMPLICATIONS
• 4.Management according to specific etiology
ALCOHOLIC LIVER CIRRHOSIS
Laboratory diagnosis of alcoholic liver cirrhosis
• Non-specific • Modest elevation in ALT ,AST and GGTP AST:ALT>2 GGT- specific for alcoholic liver disease carbohydrate deficient transferrin-most specific for alcohol abuse • Hypertriglyceridemia • Hyperbilirubinemia • Hypoalbuminemia • Decrease in platelet count USG findings: • Fatty Infiltration of liver • Portal vein flow reversal • Acitis • Intra-abdominal venous collateral formation TREATMENT OF ALCOHOLIC LIVER CIRRHOSIS • Abstinence from alcohol • Adequate nutrition • Glucocorticoids: - Can be given in patients with Discriminant function >32 - Prednisone 40mg/day or Prednisolone 32mg/day for 4weeks followed by steroid tapering for next 4weeks • TNF – alpha inhibitor: Pentoxyfylline ,infliximab,or etanercept • Liver transplantation in end stage cirrhosis CIRRHOSIS DUE TO CHRONIC VIRAL HEPATITIS B / HEP C DIAGNOSIS : • Based on clinical features • Laboratory findings • Deranged liver function Tests • Serology * HepatitisB :HBsAg, Anti-HBs,HBeAg,Anti-Hbe,Quantitave HBV DNA *Hepatitis C: Quantitave HCV RNA testing , HCV genotype analysis Treatment Hepatitis B • Antiviral therapy Lamivudine ,Entecavir,tenofovir, Adefovir ,Telbivudine DOC: Entecavir 0.5mg/day or Tenofovir 300mg daily Tenofovir alafenamide-best • Peg interferon therapy Hepatitis C • PEGInterferon based antiviral therapy • Directly acting antiviral drugs velpatasavir 100mg(NS5A inhibitor)+ Sofosbuvir 400mg(NS5B inhibitor) for 12weeks • Ribavirin added in decompensated liver cirrhosis BILIARY CIRRHOSIS • Laboratory findings • AMA in 90% - against pyruvate dehydrogenase E² • Elevated bilirubin, Hypercholesterolemia • Elevated GGTP , ALP • Mild elevation in ALT ,AST • Raised IgM levels • Thrombocytopenia,leucopenia,Anemia • Liver biopsy- required in <10% AMA negative patient *loss of canals of hering * ductopenia *Florid duct lesion with non caseating granuloma. Treatment of PBC • Liver transplantation- toc in decompensated liver • Ursodeoxycholicacid(13-15mg/kg/day)- only approved drug Olny slows the rate of progression • New drug- Faresnoid x receptor antagonist – Obeticholic acid • Management of complications such as ascitis,varices,hepatic encephalopathy Cirrhosis due to NAFLD • Diagnosis • High S.ferritin levels • Blood markers- cytokeratin 18 • Fibroscan- Transient elastography • Treatment: NAFLD • Active exercises+weight reduction • NASH: weight reduction DOC : Vit.E 800 – 1000IU/day Pioglitazone,Pentoxifyilline omega 3 fatty acid consumption HEMOCHROMATOSIS • Diagnosis • SCREENING TESTS: - s.ferritin elevated(>1000ng/ml bad prognosis) - % saturation of transferrin=S.iron*100 (Cutoff is 45%) TIBC Best method : S.ferritin+PSAT • CONFIRMATORY TEST C282Y mutation • TREATMENT TOC: Phlebotomy S.c Desferrioxamine daily for 5days/week Liver transplantation- in decompensated liver cirrhosis WILSONS DISEASE • DIAGNOSIS 1. S.ceruloplasmin decreases <15mg/dl (<5mg/ml is diagnostic) 2. Total serum copper reduces 3. Urinary copper high excretion >100mg in24 hour sample 4. Hepatic tissue copper : gold standardmethod 5. Electron microscopy- tennis racquet appearance 🎾 6. MRI- T2 Hyperintensitie—*face of giant panda sign *bright claustrum sign *mercedes benz sign/trident sign • PROGNOSTIC INDEX: Nazer prognostic index considers: S.bilirubin levels, AST,PT • TREATMENT DOC: 1) D Penicillamine 500mg tid along with pyridoxine 2) Trientine given along with zinc CARDIAC CIRRHOSIS • Laboratory findings Markedly Elevated ALP in patients with cardiac diesase Aminotranferases normal or slightly elevated (AST>ALT) • TREATMENT * treatment of the underlying cardiac diesase * Diuretics * Fluid and salt intake management * Treatment of complications of liver cirrhosis 5. LIVER TRANSPLANTATION Categories • CATEGORY 1: estimated 1year mortality without transplantation of morethan 9% • CATEGORY 2: HCC diagnosed radiologically by 2 concordant modalities Based on CT: Single lesion <5cm or <3 lesions of each<3cm, without macro vascular invasion or metastasis • CATEGORY 3: Variant syndromes- refractory ascitis,hepatopulmonary Syndrome, chronic HE,intractable pruritis, polycystic liver disease, recurrent cholangitis , primary hyperlipidemia. Types of transplantation • Split liver transplantation: cadaveric donor liver is split into two-larger Rt lobe for adults and . small left lobe for children • Living donor transplantation: left lateral segment of rt lobe is used. Complications of liver transplantation • EARLY COMPLICATIONS 1. Primary graft nonfunction 2. Technical complications : hepatic artery thrombosis, anastamotic biliary stricure – may responds to endoscopic balloon dilatation and stenting or require surgical reconstruction 3. Rejection 4. Infections • LATE COMPLICATION : Recurrence of disease in the graft renal impairment due to immunosuppression by ciclosporin Metabolic syndrome Is Common in 50% transplan Chronic vascular rejection is rare in 5% cases MCQ’S 1 Which of the following is the most common cause of cirrhosis in India? A) Non alcoholic fatty liver disease B) Alcoholic liver disease C) Hepatitis B infection D) Hepatitis C infection MCQ’S 2 Which among the following is true about alcoholic cirrhosis?
A. Hepatocyte hyperplasia
B. Macronodular cirrhosis
C. Mixed micro and macronodular cirrhosis
D. Absence of Mallory Denk bodies
MCQ’S 3 Which of the following statements is not true about nonalcoholic fatty liver disease? A. Results from fat accumulation in more than 5% of hepatocytes B. Strongly associated with obesity and insulin resistance C. Associated with reduced serum ferritin levels D. Diagnosis of NASH requires presence of inflammation MCQ’S 4 Which of the following conditions is unlikely to lead to cirrhosis in a patient? A. Alpha 1 antitrypsin deficiency B. Cystic fibrosis C. Nonalcoholic steatohepatitis D. Hepatitis A MCQ’S 5 While examining a chronic alcoholic patient, you notice the given finding. Which of the following is false regarding it? A. Occurs due to alterations in the metabolism of estrogen B. Presence of even 1 lesion is abnormal C. Commonly seen over the superior vena cava territory D. Compression results in blanching followed by reappearance after release MCQ's 6. What parameters are used in calculating discriminant function? A. Prothrombin time and bilirubin B. Bilirubin, ascites and hepaticencephalopathy C. Prothrombin time, ascites and hepatic encephalopathy D. Prothrombin, Bilirubin and creatinine MCQ'S 7. A non-diabetic patient has been diagnosed with nonalcoholic steatohepatitis (NASH). Which of the following is the first-line therapy for it? A. Vit A B. Vit E C. UDCA D. Thiamine MCQ'S 8. 45-year-old chronic alcoholic presents with right upper quadrant abdominal pain and nausea. His ultrasound abdomen revealed grade 2 fatty liver. Which among the following findings is unlikely to be seen in his condition? A. AST: ALT < 2 B. Prolonged prothrombin time C. Low platelet counts D. Elevated ALP MCQ’S 9. Which of the following is the most specific marker for alcoholism? A. ALT B. GGT C. ALP C. LDH MCQ’S 10. Prednisolone therapy for alcoholic hepatitis can be started in a patient with all of the following except:
Isolation and Identification of Fungi Associated With The Spoilage of Cucumber Fruit Sold in Igbariam, Anambra State and Possible Control Method Using Lime Juice Extract
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