Cirrhoses And Its Complications

Ahmad Shavakhi .MDAssociate professor of

gastroenterology

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 On no medication

Ph.ExamPh.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

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 ?

What is the importance ?What is the importance ?

• 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

Doppler sonography : normal

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

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 •  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?

EGD

• VARICIES :GRADE 1• Portal hypertensive gasteropathy

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

Medium &large varices

Band ligation

No contraindication for Beta -blocker

ContraindicationFor Beta -blocker

Tolerate

Start Beta blocker

Home massage Home massage

After diagnosis of cirrhosis : Etiology Severity Sonography ( ordinary and doppler ) EGD Vaccination

THE END THE END