cirrhosis 18 november 2009 thomas c sodeman md associate professor of medicine chief, division of...
TRANSCRIPT
Cirrhosis
18 November 2009
Thomas C Sodeman MDAssociate Professor of Medicine
Chief, Division of Gastroenterology
Cirrhosis
• Definition
• Diagnosis
• Pathogenesis
• Treatment
• Outlook
Cirrhosis
• Definition– Distortion of hepatic architecture by fibrosis
and attempted regeneration that leads to loss of function, portal hypertension, and potential hepatocellular malignancy.
Cirrhosis
http://www.hivandhepatitis.com/2006icr/ddw/images/cirrhosis-liver.jpg
Cirrhosis
http://www.pathology.vcu.edu/education/gi/images/3.3h-b.jpg
Cirrhosis
• Causes– Alcohol– NASH– HBC, HCV, HDV– Iron, copper– Autoimmune– PSC, PBC, SSC– Vascular– 1-AT– Drugs– ?
Cirrhosis
• Diagnosis– Clinical– Laboratory– Radiologic
Cirrhosis
• Diagnosis– Clinical
• Silent• Ascites• Encephalopathy• Sleep-wake reversals• Variceal bleeding• Muscle wasting• Gynecomastia• Spiders
Cirrhosis
Cirrhosis
http://www.hepatitis.cl/images/varices.jpg
Cirrhosis
http://www.medscape.com/content/2000/00/40/55/405535/art-mgi7381.lang.Fig2.jpg
Cirrhosis
http://content.answers.com/main/content/wp/en/thumb/9/91/200px-IGV1.jpg
Cirrhosis
• Diagnosis– Laboratory
• Synthetic defect– Albumen, INR
• Thrombocytopenia• Ammonia• Bilirubin• AST / ALT• FP
Cirrhosis
• Diagnosis– Radiologic– Can rule in but not rule out– Sensitivity and specificity of 80%– Splenomegaly, varices, ascites
Cirrhosis
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• Diagnosis– Biopsy
• 1% risk of complications• Often understages• Misdiagnosed in 10-30%• Optimal biopsy 40 mm• Average 16 mm
Cirrhosis
• Diagnosis– Noninvasive
• Fibroscan• Fibrosure• Actitest• AST/platelet ratio
( AST / ULN)/PLT (109/L)×100.
Cirrhosis
• Pathogenesis
Cirrhosis
Cirrhosis
• Treatment– Treat underlying disease– Treat manifestations– Screen for problems
• Varices• HCC
– Transplantation
Cirrhosis
• Treatment– Treat underlying disease– HBV/HCV – slow progression– HHC – slow progression– AIH – slow progression– EtOH – slow progression
Cirrhosis
• Treatment– Treat manifestations
• Ascites• Encephalopathy• Varices
Cirrhosis
Cirrhosis
• Treatment– Treat manifestations
• Ascites– Tap– SAAG >1.1– Culture– Cytology– Albumen
• Lasix / aldactone• Salt restriction 2g/day• Tap / TIPS
Cirrhosis
• Treatment– Treat manifestations
• Ascites– SAAG– >1.1 Cirrhosis, CHF, Mets, FHF, Budd-Chiari– <1.1 Peritoneal Ca, TB, bile leak, nephrotic syndrome
Cirrhosis
• Treatment– Treat manifestations
• Ascites– Tap– 1100 LVP– INR 8.7– Plt 19– No major complications
Hepatology 2004: 40:484-488
Cirrhosis
• Treatment– Treat manifestations
• Ascites– “Failure”– High salt diet– IV fluids– NSAIDS
Hepatology 2004: 40:484-488
Cirrhosis
• Treatment– Treat manifestations
• Ascites– SBP– >250 PMN– Cefotaxime– Quinolones
Hepatology 2004: 40:484-488
Cirrhosis
• Treatment– Treat manifestations
• Hepatorenal syndrome• GFR>1.5 or CrCl <40• No shock, infection, etc• Urine protein <500 mg/day
Hepatology 2004: 40:484-488
Cirrhosis
• Treatment– Treat manifestations
• Hepatorenal syndrome• Current treatment
– Preventive– Transplant– Midodrine / octreotide
Hepatology 2004: 40:484-488
Cirrhosis
• Treatment– Treat manifestations
• Varices– Predict with thrombocytopenia– Grading I-IV– Bleeding risk with III IV– Screen
» Repeat in 1-2 years if grade I or II» Repeat in 6 months if III IV
Cirrhosis
• Treatment– Treat manifestations
• Varices– Bleeding carries up to 50% mortality– Transfusion to Hb 8– Octreotide– Intubation– Endoscopy– blockers– Antibiotics for SBP
Cirrhosis
• Outlook– Bad– Mortality
• Compensated• Decompensated
– Variceal bleed 20%– Ascites 50% 2 year
Cirrhosis
• Outlook– Hepatocellular carcinoma
• Risk 1-5%/year• Increased with:
– Male– Iron– HBV– 1AT
Cirrhosis
• Outlook– Transplantation
• HCV/alcohol• NASH• HCC• PBC/PSC
Cirrhosis
• Outlook– Transplantation
• MELD score• MELD Score = 10 {0.957 Ln(Scr) + 0.378 Ln(Tbil)
+ 1.12 Ln(INR) + 0.643}
Cirrhosis
• Key points– Diagnosis
• Anything fixable?
– Management of manifestations– Screening for problems– Transplantation