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Acute and Chronic Liver Disease
Dr. Orla Crosbie
Consultant Gastroenterologist, CUH
4th Med, 17th Nov 2010
Contents
• Investigations
• Acute Liver disease
• Chronic Liver Disease
Normal Liver Function
• Protein synthesis and degradation: – albumin, transport proteins, clotting factors,
• Carbohydrate metabolism• Lipid metabolism• Bile acid metabolism• Bilirubin metabolism• Hormone inactivation• Drug inactivation and excretion• Immunological function
Liver function tests 1
• Bilirubin – Conjugated and Unconjugated• ALT/AST levels• Alkaline Phosphatase• gGT• Albumin• INR
• FBC
Liver function tests 2
• Hepatitis antibodies: A, B, C….D, E• EBV, Toxo, CMV, Leptospirosis
• Ferritin and fasting transferrin saturation, • Haemochromatosis genetics
• Caeruloplasmin and copper (serum),• 24 hour urine for copper
• Autoantibodies: ANA, ASMA, AMA, Coeliac• Immunoglobulins: IgG, IgA, IgM • Cholesterol, triglycerides, glucose, TFTs 1antitrypsin levels + phenotype fetoprotein (cirrhotics only)
Imaging
• Ultrasound – Liver substance, lesions, gallbladder and biliary tree, vessels (Doppler exam), spleen size and varices
• CT scan – confirm small lesions, see pancreas• MRI of Liver – classify smaller lesions • MRCP: Magnetic resonance
cholangiopancreatography, to see the biliary tree• ERCP: Endoscopic retrograde
cholangiopancreatography– diagnostic and therapeutic: stones, strictures etc.
MRCP
ERCP
Liver Biopsy
• Very useful for confirming a diagnosis, staging degree of inflammation and/or fibrosis, iron content, mass lesions
• Contraindications: Bleeding disorders, ascites, small liver, uncooperative patient
• Complications: Bleeding, pain, perforation another viscus, biliary leak, pneumothorax
• Methods: Percutaneous, transjugular, laparoscopically
Jaundice
• Pre hepatic – Haemolysis– Conjugation abnormalities
• Hepatic – any liver disease, acute or chronic
• Post hepatic – Obstruction
Gilberts syndrome
• Deficient glucuronyl transferase
• Unconjugated hyperbilirubinaemia, other LFTs normal
• 2-5% population
• Jaundice when dehydrated
• Low grade haemolysis
• Normal liver, life expectancy etc.
Acute Liver Disease
• Infections – Viral Hepatitis A, B, C, D, E, EBV, CMV, HSV, – Others – Leptospirosis, Toxoplasma,
• Drugs – MANY – HERBALS/OTC
• Alcohol
• Poisons
• Vascular obstruction (eg. Budd Chiari)
Acute Liver Disease
• SYMPTOMSNausea & vomiting, diarrhoea, cholestasis, pyrexia,
abdominal pain, jaundice
Fulminant/acute liver failure rare, patient very unwell coagulopathy and encephalopathic
• SIGNSJaundice, hepatomegaly, abdominal tenderness +
splenomegaly, flap/foetar
Acute Liver Disease: treatment
• Supportive mainly• Remove precipitating cause if known eg. drugs• Treat some cases eg. Leptospirosis, some viral
infections in acute phase,• Expect complications and treat as they arise eg:
– Infection– Bleeding
• Outcome– Resolve– Worsen and develop FLF (? Transplant)– Progress to chronic liver disease, may require specific therapy*
Paracetamol toxicity
• Present in many preparations***• 10gms (20 tablets) can cause fatal liver failure• Initial N&V often settles with symptoms of liver
failure developing 2-3 days later• Coagulopathy and raised ALT• Paracetamol levels may be low/neg by this stage• High index of suspicion• Treat if in any doubt with N-acetylcysteine
Chronic Liver Disease
• Alcohol• Autoimmune – autoimmmune hepatitis, PBC (Primary
Biliary cirrhosis), PSC (Primary Sclerosing Cholangitis)• Haemochromatosis• Chronic Viral hepatitis: B & C• Non-alcoholic fatty liver disease (NAFLD)• Drugs (MTX, amiodarone)• Cystic fibrosis, 1antitryptin deficiency, Wilsons disease, • Vascular problems (Portal hypertension + liver disease)• Cryptogenic• Others: sarcoidosis, amyloid, schistosomiasis
Chronic Liver Disease - symptoms
• None• Fatigue• Malnutrition• Ascites, ankle oedema, pleural effusions –
weight gain• Impotence• Bleeding• Jaundice, itch, steatorrhoea
Alcohol
• Fatty liver – may have no symptoms• Alcoholic Hepatitis – can be unwell with liver
and renal failure, jaundice, coagulopathy• Cirrhosis and its complications
• Can present at any stage above• ACCURATE ALCOHOL HISTORY• Clues: LFTS: gGT, MCV• Other problems: medical (pancreatitis,
malnutrition, infections, cardiac), social….
Tx. Of Alcoholic Hepatitis
• Feed (Enterally) • Vitamin replacement: Thiamine: IV Pabrinex and
multivitamins• Treat DTs• Corticosteroids if Maddrey’s discriminant function
higher than 32:– 50% mortality rate
• mDF= 4.6 x (PT patient-control) + Bilirubin/17.1 umol/L
• Treat with steroids: Prednisolone 40mg X1/12• Other scoring systems: Glasgow Alcoholic
Hepatitis Score, MELD score
Fatty Liver• Many Secondary causes of fatty liver, including drugs,
alcohol, previous surgery• Primary fatty liver or non-alcoholic fatty liver disease
(NAFLD) commonly recognised now• Some patients in addition to fat on liver biopsy can have
inflammation as well (steatohepatitis) and are referred to as NASH (non- alcoholic steatohepatitis), a portion of these will develop scarring and can progress to cirrhosis over time
• Is associated with obesity, non-insulin dependent diabetes, dyslipidaemia and hypertension; considered part of syndrome X/metabolic syndrome
• Fatty liver getting more common – obesity increasing.
Hereditary haemochromatosis
• Commonest genetic problem N. European
• Progressive iron overload leading to liver disease (cirrhosis and hepatocellular carcinoma), diabetes, pigmentation, arthropathy, hypogonadism, cardiac….
• Not always symptomatic at diagnosis
Hereditary haemochromatosis
• Need high serum ferritin level and fasting transferrin saturations to make diagnosis
• Fasting Transferrin Saturation > 45%
• Raised Serum Ferritin > 350ug/L
• Genetics: C282Y and H63D mutation
• REMEMBER: MANY CAUSES OF RAISED FERRITIN
Hereditary haemochromatosis
• If HH confirmed• LFTs and ultrasound +/- Liver biopsy to
diagnose Cirrhosis• Prognosis worse if diabetic or cirrhotic at time of
diagnosis• If cirrhotic, need tumour surveillance• Treatment is phlebotomy to render iron deficient
and prevent organ damage, does not remove risk of HCC
• Life long
Chronic Liver Disease - Decompensation
• Ascites + renal failure
• GI bleeding
• Encephalopathy
• Jaundice
• Hepatocellular carcinoma
Ascites• Associated with a poor prognosis• Often associated with ankle oedema, pleural effusions• Diagnostic paracentesis: 1. Biochemistry, 2. Micro & 3. Cytology• SAAG: Serum albumin/ascites gradient > 11g/dl• Risk of Spontaneous Bacterial Peritonitis
• Therapy– Low salt diet– Diuretics: Spironolactone and Frusemide– Therapeutic large volume paracentesis – albumin replacement– Shunts – TIPS– Transplantation
• DAILY WEIGHTS, WATCH U&Es• Don’t fluid restrict
Spontaneous Bacterial Peritonitis
• Risk: Ascites and Chronic liver disease• Often vague symptoms• Diagnosis: Diagnostic paracentesis for • WCC > 250 cells/mm3 and mainly polymorphs• Culture• Usually Gram negatives• Treat antibiotics +/- albumin• Antibiotic prophylaxis
Variceal bleeding
• Due to portal hypertension
• Varices at porto-systemic anastomoses– Skin – Caput medusa– Oesophageal & Gastric– Rectal– Posterior abdominal wall– Stomal
• Medical emergency
Resuscitate patient
Good IV access
Cross-match blood and clotting factors
Emergency OGD
Band oesophageal varicesCan Inject gastric varices with glue
Manage in HDU/ITU
Terlipressin IVProphylactic antibiotics
U/sound and doppler portal vein
Rebleed: Rescope, Balloon tamponade, May need TIPPs shunt, transplant
Prevention of variceal haemorrhage
• PRIMARY PREVENTION: Have not bled– Scope all cirrhotics– If large varices: B block with Propranolol or
Band varices.
• SECONDARY PREVENTION: After bleed– Repeat banding until varices eradicated +/-
propranolol (ideally measure portal pressures)
Encephalopathy
• Confusion due to liver disease• Graded 1-4• Precipitants: GI bleed, infection, constipation,
dehydration, medication esp. sedation• Flap – asterixis and hepatic foetar
• Treat underlying cause, • Laxatives – phosphate enemas and lactulose• Rifaximin-broad non absorbed spectrum
antibiotic
Hepatorenal syndrome
• Progressive renal failure in the setting of advanced liver disease and portal hypertension
• Rule out other causes for renal failure: Pre-renal, Microscopy, ultrasound
• Type 1 (acute) and Type 2 (chronic)
• Very poor prognosis
Hepatocellular Carcinoma (Hepatoma)
• Primary Liver Cancer• Usually in setting of cirrhosis• Risk factors: Viral hepatitis B/C, Alcohol,
haemochromatosis, 1 anti-trypsin, male PBCs• Screen cirrhotics with 6 monthly u/sound and
fetoprotein levels• Diagnosis made on imaging (u/s, CT or MRI) and
FP levels in cirrhotics – biopsy usually not done• Cure: transplant or surgery• Palliation: TACE, radiofrequency ablation, Sorafenib
po.
Liver transplantation
• INDICATIONS:• Fulminant Liver failure determined by certain clinical
criteria (King’s criteria)– Paracetamol Overdose: pH, INR, creatinine and Encephalopathy– Non-paracetamol: INR, Bilirubin, age, cause, encephalopathy
• Chronic Liver Disease: Mainly for Decompensation – ascites– Uncontrolled variceal haemorrhage– Encephalopathy– Hepatoma – Milan criteria
• Disease specific criteria: Rising Bilirubin in PBC• Need to consider Q of Life and Other illnesses
Liver transplantation
• WAITING LIST: MELD scoring system
• Liver Matched by blood group and size
• Post operative – Immunosuppression to prevent rejection eg.
Tacrolimus, Mycophenolate and Steroids– Prophylaxis against infection eg. CMV, HSV, PCP– Can get graft failure, vascular thrombosis, rejection
(acute and chronic), infections, disease recurrence…
Liver disease: summary
• LFTs
• Causes of jaundice
• Causes of acute hepatitis
• Causes of cirrhosis – Risk factors
• Symptoms and Signs of liver disease – Ascites, encephalopathy & SBP, variceal haemorrhage, HCC and hepatorenal syndrome.