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DCLD

A 54-year-old man presents with swelling of the abdomen and feet for 2 months along with fatigue, nausea, and loss of appetite. His eyes have turned yellow. On examination, he is jaundiced but has no liver enlargement. His abdomen is distended but soft. There is evidence of ascites. This suggests the man has liver cirrhosis complicated by ascites and jaundice. Further workup is needed to determine the underlying cause of his cirrhosis.

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Anusha Verghese
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3K views30 pages

DCLD

A 54-year-old man presents with swelling of the abdomen and feet for 2 months along with fatigue, nausea, and loss of appetite. His eyes have turned yellow. On examination, he is jaundiced but has no liver enlargement. His abdomen is distended but soft. There is evidence of ascites. This suggests the man has liver cirrhosis complicated by ascites and jaundice. Further workup is needed to determine the underlying cause of his cirrhosis.

Uploaded by

Anusha Verghese
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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54 year old gentleman presents to his GP

with increasing swelling of his abdomen


and feet over the last 2 months. He has
been increasing tired over this time and
feels nauseous and is off his food. His
wife has commented that his eyes have
turned yellow over the last few days. He
works in a warehouse and smokes 10
cigarettes a day. He admits to drinking
4 cans of lager a night. His wife says he
drinks at least 8 cans a night and a
bottle of whisky a week.
On examination he is jaundiced but has
no hepatic flap and is orientated in time,
place and person. His abdomen is
distended but soft and non-tender.
There is no palpable organomegaly but
there is shifting dullness.

Decompensated Alcoholic liver


disease
Viral liver disease
Autoimmune liver disease, Wilsons,
HH etc
Hepatocellular Carcinoma
Pancreatic Cancer
Cryptogenic Liver Cirrhosis

Cirrhosis is defined
histologically as a diffuse
hepatic process characterized
by fibrosis and the conversion
of normal liver architecture into
structurally abnormal nodules

Viral Hepatitis B, C.
Alcoholic liver disease.
Non-alcoholic fatty liver
disease (NAFLD).
Autoimmune hepatitis.
Primary biliary cirrhosis.
Secondary biliary cirrhosis
(associated with chronic
extrahepatic bile duct
obstruction).
Primary sclerosing cholangitis.
Hemochromatosis

Wilson disease.
Alpha-1 antitrypsin deficiency.
Granulomatous disease (eg,
sarcoidosis).
Type IV glycogen storage
disease.
Drug-induced liver disease (eg,
methotrexate, alpha
methyldopa, amiodarone).
Venous outflow obstruction
(eg, Budd-Chiari syndrome,
veno-occlusive disease).
Cardiac cirrhosis: chronic
right-sided heart failure,
tricuspid regurgitation

Alkalosis.
Hypokalemia.
GIT bleeding.
Hypotension.
Hepatotoxic drugs.
Infection.
Diuretic therapy.
General anesthesia.

1) Liver:
Hyper-bilirubinemia (d.t
secretory function of the liver).
Hypo-albuminemia (d.t
synthetic function) tissue
edema, ascites, pleural effusion.
Elevated liver enzymes as a result
of hepatocellular damage.

2) GIT:
Portal hypert
Variceal Bleeding
Ascites:
SBP
3) Renal: Hepato-renal Syndrome

It is the occurrence of acute


renal dysfunction in patients
with preexisitng liver failure in
the absence of primary renal
disease.

A) Hepato-pulmonary
Syndrome (HPS)
This is the presence of abnormal
intrapulmonary vascular
dilatation that can cause
profound hypoxemia

(B) Porto-pulmonary
hypertension (PPHTN)
PPHTN is defined as the
presence of a mean PAP
greater than 25 mmHg in the
presence of normal PCWP.
and can be very difficult to
treat.

5) CNS changes: Hepatic


encephalopathy
Hepatic encephalopathy is a
syndrome marked by
personality changes, intellectual
impairment, and a depressed
level of consciousness occurring
as a result of diversion of portal
blood into the systemic
circulation (porto-systemic
shunting).

Grade 0 - Subclinical; normal mental status,


but minimal changes in memory,
concentration, intellectual function,
coordination.
Grade 1 - Mild confusion, euphoria or
depression, decreased attention, slowing of
ability to perform mental tasks, irritability,
disorders of sleep pattern (ie. inverted sleep
cycle).
Grade 2 - Drowsiness, lethargy, gross
deficits in ability to perform mental tasks,
obvious personality changes, inappropriate
behaviour, intermittent disorientation
(usually for time). Diminished short term
memory and concentration. Asterixis on
physical examination.
Grade 3 - Somnolent but arousable, unable
to perform mental tasks, disorientation to
time and place, marked confusion, amnesia,
occasional fits of rage, speech is present but
incomprehensible.
Grade 4 - Coma, with or without response to
painful stimuli.

Anemia:
Thrombocytopenia
Coagulopathy

7) Metabolic changes:

Na and water retention


Hypokalemia:
Dilutional hyponatremia
Hyperkalemia
Hypomagnesemia

Child-Turcotte-Pugh Scoring System for


Cirrhosis (Child Class A=5-6 points, Child
Class B =7-9 points, Child Class C=10-15
points).

Acid base disorders:

Respiratory alkalosis: due to


hyperventilation 2ry to ascites
and hepatopulmonary $ (most
common).
Metabolic alkalosis: due to Klosing diuretics,
hyperaldosteronism, or vomiting.
Metabolic acidosis: in renal
failure

8) CVS changes:
Hyperdynamic circulatory state due
to:
Peripheral vasodilation by
endogenous vasodilators that
bypass hepatic metabolism (NO
and glucagon).
Portal and systemic shunts.

Endoscopy
Gastric

lavage
anti-shock measures
Vasopressin infusion
Balloon tamponade
Emergency sclerotherapy
IV nitro-glycerine and
propranolol
Octreotide
H2 Blockers:

Lactulose
colonic lavage
Neomycin
Rifaximin
Flumazenil

Expansion of intravascular volume


with albumin & FFP. Proper
hydration.
Avoid nephrotoxic drugs as:
aminoglycosides, cyclosporine and
contrast dyes.
Mannitol to prevent renal failure.
Hemodialysis.
Liver transplantation: kidney
function usually recovers when
patients with cirrhosis and
hepatorenal syndrome undergo
liver transplantation.
If end stage renal failure develops
combined liver-kidney
transplantation is needed.

Caloric requirements:
25-30 Kcal/Kg/day of
normovolemic BW.

Protein requirements:

Ptn restriction is controversial


but still routinely
implemented).
Amount: 40-60 g/day or
0.8g/kg/day (of normovolemic BW).
Type: rich in branched chain
(non-aromatic) amino acids.
Some studies support that
parentral ptn carries less risk of
encephalopathy since not converted
by colonic bacteria into NH3.

Micronutrients: Thiamine, folic


acid, Mg, Zn.

Medications associated with


drug-induced liver disease
include:

NSAIDs
Isoniazide
valproic acid
Erythromycin
amoxicillin-clavulanate
Ketoconazole
chlorpromazine

Aminoglycosides are
considered obligate
nephrotoxins in patients with
cirrhosis and should be
avoided.

Acetaminophen
NSAID

Opiate

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