Kandelaki Acute and Chronic Liver Disease

7/23/2019 Kandelaki Acute and Chronic Liver Disease

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Acute and Chronic

Liver Disease



Contents

• Investigations

• Acute Liver disease

• Chronic Liver Disease



Normal Liver Function

• Protein synthesis and degradation: – albumin, transort roteins, clotting !actors,

• Carbohydrate metabolism

• Liid metabolism• "ile acid metabolism

• "ilirubin metabolism

• #ormone inactivation• Drug inactivation and e$cretion

• Immunological !unction



Liver !unction tests %

• "ilirubin – Con&ugated and 'ncon&ugated

• AL()A*( levels

• Al+aline Phoshatase• g(

• Albumin

• IN-

• F"C



Liver !unction tests .

• #eatitis antibodies: A, ", C/0D, 1• 1"2, (o$o, C32, Letosirosis

• Ferritin and !asting trans!errin saturation,• #aemochromatosis genetics

• Caerulolasmin and coer 4serum5,• .6 hour urine !or coer

• Autoantibodies: ANA, A*3A, A3A, Coeliac

• Immunoglobulins: Ig, IgA, Ig3

• Cholesterol, triglycerides, glucose, (F(sο α%antitrysin levels 7 henotyeο α−!etorotein 4cirrhotics only5



Imaging

• 'ltrasound – Liver substance, lesions, gallbladderand biliary tree, vessels 4Doler e$am5, sleensi8e and varices

• C( scan – con!irm small lesions, see ancreas• 3-I o! Liver – classi!y smaller lesions

• 3-CP: M agnetic r esonancec holangio pancreatography, to see the biliary tree

• 1-CP: E ndoscopic r etrogradec holangio pancreatography – diagnostic andtheraeutic: stones, strictures etc0



3-CP



1-CP





Liver "iosy

• 2ery use!ul !or con!irming a diagnosis,staging degree o! in!lammation and)or!ibrosis, iron content, mass lesions

• Contraindications: "leeding disorders,ascites, small liver, uncooerative atient

• Comlications: "leeding, ain, er!oration

another viscus, biliary lea+, neumothora$• 3ethods: Percutaneous, trans&ugular,

laaroscoically



9aundice

• Pre heatic

– #aemolysis

– Con&ugation abnormalities

• #eatic – any liver disease, acute or

chronic

• Post heatic – bstruction



ilberts syndrome

• De!icient glucuronyl transferase

• 'ncon&ugated hyerbilirubinaemia, other

LF(s normal

• .;<= oulation

• 9aundice >hen dehydrated

• Lo> grade haemolysis• Normal liver, li!e e$ectancy etc0



Acute Liver Disease

• Infections

– 2iral #eatitis A, ", C, D, 1, 1"2, C32, #*2,

– thers – Letosirosis, (o$olasma,

• Drugs – 3AN? – #1-"AL*)(C

• Alcohol

• Poisons• 2ascular obstruction 4eg0 "udd Chiari5



Acute Liver Disease

• *?3P(3*

Nausea @ vomiting, diarrhoea, cholestasis, yre$ia,

abdominal ain, &aundice

Fulminant/acute liver failure rare, atient very un>ell

coagulopathy and encephalopathic

• *IN*9aundice, heatomegaly, abdominal tenderness 7

slenomegaly, !la)!oetar



Acute Liver Disease: treatment

• *uortive mainly

• -emove reciitating cause i! +no>n eg0 drugs

• (reat some cases eg0 Letosirosis, some viralin!ections in acute hase,

• 1$ect comlications and treat as they arise eg: – In!ection

– "leeding

• utcome

– -esolve – orsen and develo FLF 4B (ranslant5

– Progress to chronic liver disease, may reuire seci!ic theray



Paracetamol to$icity

• Present in many rearations

• %Egms 4.E tablets5 can cause !atal liver !ailure

• Initial N@2 o!ten settles >ith symtoms o! liver

!ailure develoing .; days later

• Coaguloathy and raised AL(

• Paracetamol levels may be lo>)neg by this stage

• #igh inde$ o! susicion• (reat i! in any doubt >ith N;acetylcysteine





Chronic Liver Disease

• Alcohol

• Autoimmune – autoimmmune heatitis, P"C 4Primary"iliary cirrhosis5, P*C 4Primary *clerosing Cholangitis5

• #aemochromatosis

• Chronic 2iral heatitis: " @ C

• Non;alcoholic !atty liver disease 4NAFLD5

• Drugs 43(G, amiodarone5

• Cystic !ibrosis, α%antitrytin de!iciency, ilsons disease,

• 2ascular roblems 4Portal hyertension 7 liver disease5

• Crytogenic

• thers: sarcoidosis, amyloid, schistosomiasis



Chronic Liver Disease ; symtoms

• None

• Fatigue

• 3alnutrition

• Ascites, an+le oedema, leural e!!usions –>eight gain

• Imotence

• "leeding

• 9aundice, itch, steatorrhoea



Alcohol

• Fatty liver – may have no symtoms• Alcoholic Hepatitis – can be un>ell >ith liver

and renal !ailure, &aundice, coaguloathy

• Cirrhosis and its comlications

• Can resent at any stage above• ACC'-A(1 ALC#L #I*(-?

• Clues: LF(*: g(, 3C2• ther roblems: medical 4ancreatitis,

malnutrition, in!ections, cardiac5, social/0



($0 ! Alcoholic #eatitis

• Feed 41nterally5

• 2itamin relacement: (hiamine: I2 Pabrine$ andmultivitamins

• (reat D(s• Corticosteroids i! 3addreyHs discriminant !unctionhigher than .: – <E= mortality rate

• mDF 60J $ 4P( atient;control5 7 "ilirubin)%K0% umol)L

• (reat >ith steroids: Prednisolone 6Emg G%)%.

• ther scoring systems: lasgo> Alcoholic #eatitis*core, 31LD score



Fatty Liver

• 3any *econdary causes o! !atty liver, including drugs,alcohol, revious surgery

• Primary fatty liver or non;alcoholic !atty liver disease4NAFLD5 commonly recognised no>

• *ome atients in addition to !at on liver biosy can havein!lammation as >ell 4steatoheatitis5 and are re!erred toas NA*# 4non; alcoholic steatoheatitis5, a ortion o!these >ill develo scarring and can rogress to cirrhosisover time

• Is associated >ith obesity, non;insulin deendentdiabetes, dysliidaemia and hyertension consideredart o! syndrome G)metabolic syndrome

• Fatty liver getting more common – obesity increasing0







#ereditary haemochromatosis

• Commonest genetic roblem N0 1uroean

• Progressive iron overload leading to liverdisease 4cirrhosis and heatocellular

carcinoma5, diabetes, igmentation,

arthroathy, hyogonadism, cardiac/0

• Not al>ays symtomatic at diagnosis




• Need high serum ferritin level and fastingtransferrin saturations to ma+e diagnosis

• Fasting (rans!errin *aturation M 6<=

• -aised *erum Ferritin M <Eug)L

• Genetics: C..? and #JD mutation

• -1313"1-: 3AN? CA'*1* F -AI*1DF1--I(IN




• I! ## con!irmed

• LFTs and ultrasound 7); Liver biosy todiagnose Cirrhosis

• Prognosis >orse i! diabetic or cirrhotic at time o!diagnosis

• I! cirrhotic, need tumour surveillance

• (reatment is hlebotomy to render iron de!icient

and revent organ damage, does not removeris+ o! #CC

• Li!e long



Chronic Liver Disease ;

Decomensation

• Ascites 7 renal !ailure

• I bleeding• 1ncehaloathy

• 9aundice

• #eatocellular carcinoma







Ascites

• Associated >ith a oor rognosis

• !ten associated >ith an+le oedema, leural e!!usions

• Diagnostic aracentesis: %0 "iochemistry, .0 3icro @ 0 Cytology

• *AA: *erum albumin)ascites gradient M %%g)dl

• -is+ o! *ontaneous "acterial Peritonitis

• (heray – Lo> salt diet

– Diuretics: *ironolactone and Frusemide

– (heraeutic large volume aracentesis – albumin relacement

– *hunts – (IP*

– (ranslantation

• DAIL? 1I#(*, A(C# '@1s

• DonHt !luid restrict





*ontaneous "acterial

Peritonitis• -is+: Ascites and Chronic liver disease

• !ten vague symtoms

• Diagnosis: Diagnostic aracentesis !or

• CC M .<E cells)mmF and mainly olymorhs

• Culture

• 'sually ram negatives

• (reat antibiotics 7); albumin

• Antibiotic rohyla$is



2ariceal bleeding

• Due to ortal hyertension

• 2arices at orto;systemic anastomoses

– *+in – Caut medusa

– esohageal @ astric

– -ectal

– Posterior abdominal >all

– *tomal

• 3edical emergency



-esuscitate atient

ood I2 access

Cross;match blood

and clotting !actors

1mergency D



"and oesohageal varices

Can In&ect gastric varices >ith

glue

3anage in #D')I('

(erliressin I2

Prohylactic antibiotics

')sound and doler ortal vein

-ebleed: -escoe,

"alloon tamonade,3ay need (IPPs shunt, translant





Prevention o! variceal

haemorrhage• P-I3A-? P-121N(IN: #ave not bled

– *coe all cirrhotics

– I! large varices: " bloc+ >ith Proranolol or

"and varices0

• *1CNDA-? P-121N(IN: A!ter bleed

– -eeat banding until varices eradicated 7);

roranolol 4ideally measure ortal ressures5



1ncehaloathy

• Con!usion due to liver disease• raded %;6• Preciitants: I bleed, in!ection, constiation,

dehydration, medication es0 sedation• Fla – asteri$is and heatic !oetar

• (reat underlying cause,

• La$atives – hoshate enemas and lactulose• -i!a$imin;broad non absorbed sectrum

antibiotic



#eatorenal syndrome

• Progressive renal !ailure in the setting o!

advanced liver disease and ortal

hyertension

• -ule out other causes !or renal !ailure:

Pre;renal, 3icroscoy, ultrasound

• (ye % 4acute5 and (ye . 4chronic5

• 2ery oor rognosis





# t ll l C i



#eatocellular Carcinoma

4#eatoma5• Primary Liver Cancer

• 'sually in setting o! cirrhosis

• -is+ !actors: 2iral heatitis ")C, Alcohol,haemochromatosis, α% anti;trysin, male P"Cs

• *creen cirrhotics >ith J monthly u)sound andα!etorotein levels

• Diagnosis made on imaging 4u)s, C( or 3-I5 andαFP levels in cirrhotics – biosy usually not done

• Cure: translant or surgery

• Palliation: (AC1, radio!reuency ablation, *ora!enibo0



Liver translantation

• INDICA(IN*:

• Fulminant Liver !ailure determined by certain clinicalcriteria 4OingHs criteria5 – Paracetamol verdose: #, IN-, creatinine and 1ncehaloathy

– Non;aracetamol: IN-, "ilirubin, age, cause, encehaloathy• Chronic Liver Disease: 3ainly !or Decomensation

– ascites

– 'ncontrolled variceal haemorrhage

– 1ncehaloathy

– #eatoma – 3ilan criteria

• Disease seci!ic criteria: -ising "ilirubin in P"C

• Need to consider o! Li!e and ther illnesses



Liver translantation

• AI(IN LI*(: 31LD scoring system

• Liver 3atched by blood grou and si8e

• Post oerative – Immunosuression to revent re&ection eg0

(acrolimus, 3ycohenolate and *teroids

– Prohyla$is against in!ection eg0 C32, #*2, PCP – Can get gra!t !ailure, vascular thrombosis, re&ection

4acute and chronic5, in!ections, disease recurrence/



Liver disease: summary

• LF(s

• Causes o! &aundice

• Causes o! acute heatitis• Causes o! cirrhosis – -is+ !actors

• *ymtoms and *igns o! liver disease –

Ascites, encehaloathy @ *"P, varicealhaemorrhage, #CC and heatorenal

syndrome0

Kandelaki Acute and Chronic Liver Disease

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