cirrhoses and its complications ahmad shavakhi
TRANSCRIPT
Cirrhoses And Its Complications
Ahmad Shavakhi
The patient• A 42 y/o man presented to clinic
complaining of malaise and weakness • He was well until 2 months ago when
weakness developed• Phx was unremarkable• On no medication
Ph.Exam• Gynecomastia• Minimal ascites• spelenomegaly• Palmar erythema• Spider angioma• Clubbing• Others were normal
LAB DATALAB DATA• AST =80• ALT =60• PT =15• PTT =52• Bil .D :2.1• Bil .T :3.2
• CBC :• WBC:5600• Hb :12
(MCV=84)• PLT :68000
• Na=125
Sonographic finding Sonographic finding
Small shrinkage liver Large spleen ascites
EGD
• VARICIES :GRADE 1• Portal hypertensive gasteropathy
What is your diagnosis ?What is your diagnosis ?
• Is there any indication for liver Bx in this patient ?
Liver biopsy is not necessary if the clinical, laboratory, and radiologic data strongly suggest the presence of cirrhosis
What is the cause of cirrhosis ?
Alcoholic liver disease Nash Hepatitis B and C Hemochromatosis AIH Wilson A1AT PBC and PSC
LAB DATALAB DATA
• VIRAL MARKERS :NEG• AUTOIMMUNE MARKERS :NEG
• Alpha 1 antitrypsin :NL• Fe ,TIBC ,FERRITIN :NL
LAB DATALAB DATA
• Ascites fluid :• SAAG :2.1• WBC :52 (60% LYMPHOCYTE,40%
PMN)• CULTURE :NEG
What is the severity of cirrhosis ?
MELD scoreMELD score
MELD = 3.8[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.6[Ln serum creatinine (mg/dL)] + 6.4
CHILD-PUGH SCORING SYSTEM
1 2 3
Ascites bil.T mg/dl
Alb g/l
PT*
INR
Encephalopathy
Absent
<2
>3.5
<1.7
none
Slight
2-3
2.8-3.5
1.8-2.3 grade1-2
Moderate
>3
<2.8
>2.3
grade3-4
*: Second over control
1 2 3
• What is your dietary advice to this patient ?
Free use• Fresh and home-cooked fruit and
vegetables• Meat/poultry/fish(100g/day) and one
egg, one egg=50g meat• Unsalted butter,cooking oils,rice• Lemon juice,onion,garlic,pepper,• Fresh fruit juice• Salt free bread• Coffee,tea
Restrict• Milk(300ml)• Bread(two slices/day)
omit• Anything containig baking powder
and baking soda(biscuits ,cakes)• Commercially prepared food• Tinned /bottled vegetables• Tinned meats/fish• Cheese
Protein restriction ?
What is the program of cancer screening in this patient?
Screening for Screening for hepatocellular carcinomahepatocellular carcinoma
• periodic( every 6 months) ultrasound examination
• blood tests?
After few months we found two mass in liver
What is the next stepWhat is the next step
Biopsy MRI CT Observation
Does the patient need for vaccination ?
VaccinationVaccination
• Patients with cirrhosis are typically vaccinated against :• hepatitis A and B• Pneumococcal vaccine • standard immunizations • Haemophilus influenzae and meningococcal :who require a
splenectomy • e suggest not routinely obtaining antibody titers after immunization.
Exceptions for hepatitis B vaccine• healthcare workers, • chronic hemodialysis• gay or bisexual men• spouses of carriers
Patient has headache ? Patient has headache ?
What is your advise as pain killer ?
NSAID Acetaminophen Mixed drug COX2 inhibitors
OpioidsOpioids
Morphine :twofold increase in the interval Meperidine :dose in patients with cirrhosis
should be decreased initially by 50 percent Tramadol and fentanyl :safe
What is your idea about the exercise?
Exercise
• generally safe for patients with cirrhosis that is not in an advanced stage.
• may increase the risk of variceal bleeding in advanced disease (such as those who have ascites or varices).
Screen for encephalopathy
When do you want to perform the next EGD for follow up?
EVERY 2 Y
NO
VARICES
EVERY 1 Y
SMALL
What does the patient do for
prevention of variceal bleeding ?
Patient with small varices
(grade 1) : :
• Prophylaxis is not recommended
Prophylaxis from variceal bleeding
Not Tolerate Not Tolerate
Medium &large varicesMedium &large varices
Band ligationBand ligation
No contraindication for Beta -blocker
No contraindication for Beta -blocker
ContraindicationFor Beta -blocker
ContraindicationFor Beta -blocker
TolerateTolerate
Start Beta blocker Start Beta blocker
THE END THE END