WK 7 LIVER CIRROSIS Year 4 Internal Medicine Notes OmpathStudy

WK 7 LIVER CIRROSIS Year 4 · Internal Medicine Collection: 4TH YEAR ALL NOTES / IMED / IMED 4.1 / ALEX -- Slide 1 Cirhosis of the liver Final common pathway for many hepatic disorders\nChronic cellular distruction\nFibrosis\nregenerative nodules\nDistortion of architecture\nportal hypertention Slide 2 Defn. A diffuse process characterized by liver necrosis and fibrosis and conversion of normal liver architecture into structurally abnormal nodules that lack normal lobular organization(WHO) Slide 3 Cirhosis of the liver cont….. Classification\nmicronodular (ETOH)\nMacronodular (viral) Slide 5 Causes of cirrhosis HBV, HCV, PBC,PSC, Autoimmune Hepatitis Metabolic and genetic;Hemachromatosis,wilsons disease,AAT def Toxins-alcohol etc NAFLD Cryptogenic Secondary.Billialy.Cirrhosis Slide 6 Causes of cirrhosis cont….. Sarcoidosis Cystic fibrosis Drugs (eg Methotraxate) Glycogen storage disorder Slide 7 Pathology in liver cirrhosis Nodularity-regenerating nodules Fibrosis-deposition of dense fibrous septa Hepatocytes: abnormalities(pleomorphism, dysplasia, hyperplasia) Grossly: irregular surface, firm Slide 10 Clinical presentation General decline in health. Non specific complaints Anorexia,weight loss, fatigue, malaise,weakness Advanced stages present with:\nComplication of portal hypertension Slide 11 Clinical Presentation Conti….. Endocrine:\nDiabetes mellitus\nGynaecomastia\nPalmar erythema Pulmonary\nHypoxaemia, Pleural effusion, hepato pulmonary syndrome Slide 12 Cont. Clinical presentation.. Hemorrhagic tendency; menorrhagia,purpura,epistaxis Renal\nRenal failure 2nd degree\nHepato renal syndrome 1 Hepatic encephalopathy Slide 13 Suspect liver cirrhosis if Labs; Chronic abnormal amino transferases Low alb <3.8g/dl Prolonged prothrombin time,INR 1.3 Raised bilirubin Portal htn- thrombocytopenia AST/ALT 1 p/e Small liver span Splenomegaly Palpable left lobe of liver Stigmata of CLD; palmar erythema, muscle wasting,etc Signs of decompensation; ascites, asterixis, JN Slide 14 Diagnosis Of Liver cirrhosis Lab Tests:\nLFTS these may be normal\nCoagulation profile( INR, PTI, ) U/E/C Albumin and serum protein TBC:- platelet count, Anaemia Viral Markers: HBV, HCV\nANA, aSMA/AMA Slide 15 Diagnosis of liver cirhosis Radiology:- U/S, CT scan, MRI, Doppler U/S, ERCP/OGD Slide 16 Diagnosis of liver cirrhosis conti… Liver biopsy\ngold standard: clue to underlying cause\nrisk of bleeding\nTrans jugular approach Slide 18 Management Control of ascites Varices: beta blockers,banding,sclerotherapy Encephalopathy Screening for Hepatocellular carcinoma Liver Transplant Slide 19 Cont.mx Wilson disease-penicillamine Hemochromatosis-phlebotomy Chronic viral hepatitis-antivirals Established cirrhosis-tx complications Maintenance of nutrition Liver transplantation Slide 22 Ascitis Defination: Pathological accumulation of fluid within the peritoneal cavity Causes of Ascitis Chronic liver disease Peritoneal infections, Cirhosis, alcoholic hepatitis, carcinomatosis Heart failure Malignancy Slide 23 Causes Of Ascitis conti…. TB Fulminating Hepatic failure Pancreatitis Nephrogenous Billiary Ascitis\nSerositis\nMEIgs syndrome Slide 24 Pathogenesis of Ascitis Portal Hypertension is prerequisite for ascites formation in liver disease SAAG Raised 1.1gldl Peripheral arterial vasodilation theory Slide 25 Clinical Presentation History helps evaluate cause of ascites Alcohol intake Hx of unprotected sex HBV, HCV Family Hx of wilsons, Hemachromatosis Slide 26 Presentation symptoms and signs Jaundice, pedal edema G.I bleeding Encelephalopathy Wt loss – cancer Cardiomyopathy-Heart Dx,\nfever, night sweating -TB Slide 27 Physical Examination DD of Ascitis\nMassive hepatomegaly\nGaseous distention\nPregnancy\nIntra abdominal masses\nShifting dullness\nPuddle sign approx. 120mls Slide 28 Stigmata of chronic liver disease Stigmata of chronic liver disease\nPalmar erythema\ngynaecomastia\nsplenomegally, \nSpider Naevi Slide 29 Lab Test Blood test: LFTS,TBC,U/E/C\nAscitis fluid testing, Microscopy,cultural\nSAAG, Cytology, LAD, Glucose Slide 30 Management Paracentecis- up for 5 litre Diuretics Furosemide and Spironolactone Slide 31 Bacterial Peritonitis Slide 32 Spontaneous Bacterial peritonitis Defination Ascitic fluid infection with pure growth of a single organism, ascitic neutrophil count.250 cell/ul with no evidence of surgically correctable cause Occurs in setting of liver disease, nephrotic syndrome Agents\nE.coli klebsiella pneumonae and pneumococcus most common \nanaerobes~ 1% Slide 33 Clinical Features 85 % of patient SBP Fever Abdominal pain Change in mental status\n\nTreatment Antibiotics when cell count is 250 cell/ micro litre before cultures result 3rd generation cephalosporins Fluroquinolones 5-10days Slide 34 Treatment Abx for empirical tx: Iv cefotaxime, amoxicillin –clavulanic acid Oral norfloxacin(uncomplicated peritonitis) No aminoglycosides Re-evaluate if ascitic fluid PMN count has not decreased by at least 25 % after 2 days of tx Min