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7/23/2019 Kandelaki Acute and Chronic Liver Disease
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Acute and Chronic
Liver Disease
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Contents
• Investigations
• Acute Liver disease
• Chronic Liver Disease
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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$cretion
• Immunological !unction
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Liver !unction tests %
• "ilirubin – Con&ugated and 'ncon&ugated
• AL()A*( levels
• Al+aline Phoshatase• g(
• Albumin
• IN-
• F"C
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Liver !unction tests .
• #eatitis antibodies: A, ", C/0D, 1• 1"2, (o$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
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Imaging
• 'ltrasound – Liver substance, lesions, gallbladderand biliary tree, vessels 4Doler e$am5, sleensi8e and varices
• C( scan – con!irm small lesions, see ancreas• 3-I o! Liver – classi!y smaller lesions
• 3-CP: M agnetic r esonancec holangio pancreatography, to see the biliary tree
• 1-CP: E ndoscopic r etrogradec holangio pancreatography – diagnostic andtheraeutic: stones, strictures etc0
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3-CP
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1-CP
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Liver "iosy
• 2ery use!ul !or con!irming a diagnosis,staging degree o! in!lammation and)or!ibrosis, iron content, mass lesions
• Contraindications: "leeding disorders,ascites, small liver, uncooerative atient
• Comlications: "leeding, ain, er!oration
another viscus, biliary lea+, neumothora$• 3ethods: Percutaneous, trans&ugular,
laaroscoically
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9aundice
• Pre heatic
– #aemolysis
– Con&ugation abnormalities
• #eatic – any liver disease, acute or
chronic
• Post heatic – bstruction
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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$ectancy etc0
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Acute Liver Disease
• Infections
– 2iral #eatitis A, ", C, D, 1, 1"2, C32, #*2,
– thers – Letosirosis, (o$olasma,
• Drugs – 3AN? – #1-"AL*)(C
• Alcohol
• Poisons• 2ascular obstruction 4eg0 "udd Chiari5
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Acute Liver Disease
• *?3P(3*
Nausea @ vomiting, diarrhoea, cholestasis, yre$ia,
abdominal ain, &aundice
Fulminant/acute liver failure rare, atient very un>ell
coagulopathy and encephalopathic
• *IN*9aundice, heatomegaly, abdominal tenderness 7
slenomegaly, !la)!oetar
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Acute Liver Disease: treatment
• *uortive mainly
• -emove reciitating cause i! +no>n eg0 drugs
• (reat some cases eg0 Letosirosis, some viralin!ections in acute hase,
• 1$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
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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
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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
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Chronic Liver Disease ; symtoms
• None
• Fatigue
• 3alnutrition
• Ascites, an+le oedema, leural e!!usions –>eight gain
• Imotence
• "leeding
• 9aundice, itch, steatorrhoea
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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
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($0 ! Alcoholic #eatitis
• Feed 41nterally5
• 2itamin relacement: (hiamine: I2 Pabrine$ 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
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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
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#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
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#ereditary haemochromatosis
• 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
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#ereditary haemochromatosis
• 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
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Chronic Liver Disease ;
Decomensation
• Ascites 7 renal !ailure
• I bleeding• 1ncehaloathy
• 9aundice
• #eatocellular carcinoma
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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
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*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$is
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2ariceal bleeding
• Due to ortal hyertension
• 2arices at orto;systemic anastomoses
– *+in – Caut medusa
– esohageal @ astric
– -ectal
– Posterior abdominal >all
– *tomal
• 3edical emergency
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-esuscitate atient
ood I2 access
Cross;match blood
and clotting !actors
1mergency D
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"and oesohageal varices
Can In&ect gastric varices >ith
glue
3anage in #D')I('
(erliressin I2
Prohylactic antibiotics
')sound and doler ortal vein
-ebleed: -escoe,
"alloon tamonade,3ay need (IPPs shunt, translant
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Prevention o! variceal
haemorrhage• P-I3A-? P-121N(IN: #ave not bled
– *coe all cirrhotics
– I! large varices: " bloc+ >ith Proranolol or
"and varices0
• *1CNDA-? P-121N(IN: A!ter bleed
– -eeat banding until varices eradicated 7);
roranolol 4ideally measure ortal ressures5
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1ncehaloathy
• Con!usion due to liver disease• raded %;6• Preciitants: I bleed, in!ection, constiation,
dehydration, medication es0 sedation• Fla – asteri$is and heatic !oetar
• (reat underlying cause,
• La$atives – hoshate enemas and lactulose• -i!a$imin;broad non absorbed sectrum
antibiotic
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#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
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# t ll l C i
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#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
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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
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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/
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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