dr allister j grant consultant hepatologist university hospitals leicester nhs trust
DESCRIPTION
Dr Allister J Grant Consultant Hepatologist University Hospitals Leicester NHS Trust. IVC. Portal Vein. Hepatic Artery. Splenic Vein. CBD. Gallbladder. SMV. Anatomy &Physiology. Anatomy &Physiology. Liver Functions. Nutrition/Metabolic – stores glycogen (glucose chains) - PowerPoint PPT PresentationTRANSCRIPT
Dr Allister J GrantConsultant Hepatologist
University Hospitals Leicester NHS Trust
Anatomy &Physiology
Hepatic Artery
IVC
Splenic Vein
SMVGallbladder
Portal Vein
CBD
Anatomy &Physiology
Liver Functions
Nutrition/Metabolic– stores glycogen (glucose chains)– releases glucose– absorbs fats, fat soluble vitamins– manufactures cholesterol
Bile Salts– lipids derived from cholesterol– dissolves dietary fats (detergent)
Bilirubin– breakdown product of haemoglobin
Liver Functions
Clotting Factors– manufactures most clotting factors
Immune function– Kupfer cells engulf antigens (bacteria)
Detoxification– drug excretion (sometimes activation)– alcohol breakdown
Manufactures Proteins– albumin– binding proteins
Disease Progression
Acute Liver Failure
• <6 weeks duration
• Jaundice• Encephalopathy• Cerebral Oedema• Acute Renal Failure• Acidosis• Hypoglycaemia• MOF
Chronic Liver Disease
• >6 months
Cirrhosis leading to
• Recurrent decompensation– Ascites– Portal Hypertension (variceal
bleeding)– Encephalopathy
• Low albumin/Malnutrition• Hepatorenal syndrome• Hyponatraemia• Hepatoma
Disease ProgressionL
iver
fu
nct
ion
100%
Cirrhosis
Liver Failure
Years
A
B
CD
24♀ 48hours post POD
• ALT 13000• Alb 35• Bili 40
• Cr 160• Urea 24
• INR 3.0• PT 33
• Glc 3.6
• Ph 7.1
• PCO2 3.2
• PO2 12.4
• BE -6
ALF
• Treat the underlying cause• Resuscitate - Central access early • Give N-Ac regardless of cause• Monitor for hypoglycaemia• Monitor coagulopathy• Antibiotic prophylaxis• Stress Ulcers• Early elective ventilation for encephalopathy• Nutrition• Acidosis/ Renal Impairment
• Early referral to Hepatology / discuss with Birmingham Liver Unit
Mrs W
• 48 year old ♀ admitted from a surgical clinic with jaundice and unwell
• Unwell for 6 wks after holiday in Mexico
• Hx of xs alcohol 30u/wk
• No previous jaundice
• USS normal size liver and spleen – biliary tree normal
OE
• Jaundice• Drowsy• Agitated/Irritable• Doesn’t obey
commands• No stigmata of CLD• Asterixis
No spleenNo ascites
Mrs W
• U&E normal
• ALP 107• ALT 736• Bili 363• Alb 24
• FBC Normal
• INR 3.7
Causes of Acute Liver Failure
• Drugs• Paracetamol (UK)• INH• Halothane• Ecstacy
• Viral• Hepatitis A• Hepatitis B• Hepatitis E• Non-A Non-B
• Wilsons Disease
• Autoimmune Hepatitis
• Reye’s Syndrome
• Cardiovascular• Ischaemic hepatitis• Budd Chiari
• Acute Fatty Liver of Pregnancy
Encephalopathy
• Grade 1» Constructional apraxia» Poor memory – number connection test» Agitation/ irritability» Reversed sleep pattern
• Grade 2» Lethargy, disorientation» Asterixis
• Grade 3» Drowsy, reduced conscious level
• Grade 4» Coma
Cirrhosis
Expanded Portal Tracts(Blue)
Signs of Chronic Liver Disease
• None• Asterixis/Flap• Relative hypotension• Oedema• Jaundice/No jaundice• Large/Small liver• Splenomegaly• Gynecomastia• Testicular atrophy-loss of secondary sexual
characteristics• Impotence
Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
The Development of Ascites
50% of compensated cirrhotics develop ascites over 10yrs
50% of cirrhotics with ascites will die within 2 yrs
(50% 2yr rule for OLTx assessment)
The Development of Ascites
Peripheral arterial dilatation
Reduced effective blood volume
Activation of renin-angiotensin-aldosterone systemSympathetic nervous systemADH
Na retention &Water retention
Low urinary NaDilutional hyponatraemia
AscitesSchrier et al Hepatol 1988
Plasma volume expansion
NaCl
Ascites and Oedema
General Management
Ascites and Oedema
• Salt restriction
• Diureticsspironolactonefrusemide
• Water restriction if sodium < 125 mmol
• Paracentesisdiagnostic (SBP, tumour)therapeutic (20% Alb)
• DAILY WEIGHTS!
Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
Causes of EncephalopathyINCREASED AMMONIAGENESIS
Increased substrate (protein) for ammoniagenesis
– Increased protein intake– Gastrointestinal bleeding– Constipation– Dehydration
Increased substrate (urea) for ammoniagenesis
– Renal failure
Increased catabolism of protein
– Infection– Hypokalemia– Sepsis
DECREASED HEPATOCELLULAR FUNCTION
– Worsened intrinsic liver disease– Hypoxia – Anaemia – Development of hepatocellular carcinoma – Dehydration – Hypotension – Sepsis– Drug toxicity – Superimposed viral hepatitis
Causes of Encephalopathy
INCREASED PORTOCAVAL SHUNTING
– Portal vein thrombosis – Transjugular intrahepatic portosystemic shunt formation – Surgical shunt formation – Spontaneous shunt formation
PSYCHOACTIVE DRUG USE
– Benzodiazepines – Ethanol – Antiemetics– Antihistamines – Others
Causes of Encephalopathy
General ManagementEncephalopathy
Minimize effects of liver disease
Treat precipitants• sepsis• GI bleed• medications (over-diuresis)
Avoid sedatives, hypnotics, opiates
Lactulose to ensure BO 2x/day
Metronidazole/ neomycin
Decompensation in Cirrhosis
Means the development of-
Ascites
Hepatic Encephalopathy
Portal hypertension (variceal haemorrhage)
Portal Circulation
Oesophageal varices
Management of Bleeding Varices
• Prevention
• Prophylactic Antibiotics
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
Management of Bleeding Varices
• Prevention
• Prophylactic Antibiotics
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
Fluid Management
• Crystalloid
• Colloid
• Blood
• Platelets
• FFP
• Vitamin K
Management of Bleeding Varices
• Prevention
• Prophylactic Antibiotics
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
Oesophageal varices
Bleeding Gastric Varices
Variceal Bander
Variceal Band Ligation
Management of Bleeding Varices
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin 2mg qds i.v
• Balloon Tamponade
• TIPS
Management of Bleeding Varices
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
Sengstaken-Blakemore Tube
Complication of SBT
Management of Bleeding Varices
• Resuscitation
• Endoscopy - Band LigationSclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS
The End“All right, let's not panic.
I'll make the money by selling one of my livers.I can get by with one “
Doh!