Liver Cirrhosis .pdf

Portal hypertension a condition which describe the fibrotic tissue replaces normal hepatic parenchyma, resistance to blood flow results in the clinical problems of: Definition Stages of liver disease Healthy liver Development of varices and ascites Deposit of fat cause liver enlargement . 2.F...

Portal hypertension a condition which describe the fibrotic tissue replaces normal hepatic parenchyma, resistance to blood flow results in the clinical problems of: Definition Stages of liver disease Healthy liver Development of varices and ascites Deposit of fat cause liver enlargement . 2.Fatty liver Scar tissue forms, more liver cell injury occurs. 3.Liver fibrosis Scar tissue makes liver hard and unable to work properly. 4.Cirrhosis Glucose Vitamins B12, D,K Storage Copper Iron Insulin Billirubin Degradation Ammonia to urea Drugs Gluconeogenesis Functions of the Liver Carbohydrates Glycogenesis Glycogenolysis Metabolism Cholesterol synthesis Lipid Lipogenesis Serum albumin Coagulation factors (l, ll, V, Vll, lX, XI, Protein C, Protein S, Antithrombin) C- Reactive protein Carrier proteins ( Ceruloplasmin, albumin, haptoglobin) Synthesis Hormones ( Thrombopoietin, IGF-1) Pro-Hormones (Angiotensinogen) Apolipoproteins Complement proteins Non - Essential amino acids Alcohol Methotrexate Isoniazed Amoxicillin-clavulanate Drugs and toxins Nevirapine Propylthiouracil Methyldopa Organic Hydrocarbons Viral hepatitis Infections Schistosomiasis Primary biliary cirrhosis Autoimmune hepatitis Immune-Mediated Cholangitis Hemochromatosis Porphyria Etiology Category Metabolic Wilson’s disease α1 antitrypsin deficiency Cystic fibrosis Atresia Biliary obstruction Strictures Gallstones Chronic right heart failure Cardiovascular Veno-occlusive disease Unknown Cryptogenic Nonalcoholic steatohepatitis Others Sarcoidosis Gastric bypass Asymptomatic Hepatomegaly and Splenomegaly Pruritus Jaundice Palmar erythema Spider angiomata Hyperpigmentation Clinical Manifestations Signs & Symptoms Liver Cirrhosis Gynecomastia & Reduced libido Ascites Edema Pleural effusion Respiratory difficulties Malaise Anorexia Weight loss Encephalopathy Viral Alcoholic Toxic Autoimmune Classification of liver cirrhosis (etiologic) Metabolic Congestive Biliary Cryptogenic Scoring for the Child-Pugh Grading of Liver Disease Severity of disease Compensation stage Sub compensation stage Decompensation stage Portal hypertension Complications Esophageal varices Ascites Esophageal and gastric varices and variceal bleeding may arise after a hepatic venous pressure gradient (HVPG) of 10 mm Hg is reached. accumulation of fluid in the peritoneal space. It is the most common condition associated with decompensated cirrhosis. HE and coagulation disorders Avoiding additional hepatic insult Lifestyle modifications Recommended in patients with cirrhosis to prevent additional liver damage from an acute viral infection. Hepatitis A and B vaccination Vaccination May also be appropriate and can reduce hospitalizations. Pneumococcal and influenza vaccination Patients with ascites require dietary sodium restriction, Intake should be limited to less than 800 mg sodium per day. Non pharmacological therapy Ascites usually responds well to sodium restriction accompanied by diuretic therapy. In patients with variceal bleeding, nasogastric (NG) suction reduces the risk of aspirating stomach contents. During episodes of acute HE, temporary protein restriction to decrease ammonia production can be a useful adjuvant to pharmacologic therapy. A channel that create a communication pathway between the intrahepatic portal vein and the hepatic vein. Transjugular Intrahepatic Portosystemic Shunts (TIPS) Used to stop acutely bleeding varices. It is effective in stopping acute variceal bleeding in up to 90% of patients. Endoscopic band ligation first-line treatments for portal hypertension. They reduce bleeding and decrease mortality in patients with known varices. Nonselective β-blockers Because β-blockers decrease blood pressure and heart rate Propranolol & Nadolol they should be started at low doses to increase tolerability. Starting dose of propranolol is 10 to 20 mg once or twice daily. suggested for patients who do not achieve therapeutic goals with β-blocker therapy alone. Portal Hypertension Treatment alone and in combination with β-blockers, reduced portal pressure in clinical trials. Nitrates They increase mortality when used alone. Isosorbide mononitrate Current evidence only supports use of the combination to prevent re- bleeding, not for primary prophylaxis. an aldosterone antagonist with or without furosemide forms the basis of pharmacologic therapy for ascites. usually required in addition to sodium restriction. Spironolactone Cirrhosis is a high aldosterone state; spironolactone counteracts the effects of RAAS activation. In cirrhosis, not only is aldosterone production increased, but its half-life is also prolonged because of decreased hepatic metabolism. Ascites Diuretics A ratio of 40 mg furosemide to 100 mg spironolactone (the most common starting dose for cirrhosis) can usually maintain serum potassium concentrations within the normal range. The maximum amount of ascitic fluid that can be removed through diuresis is approximately 0.5 L/day. Pharmacological Therapy It causes selective vasoconstriction of the splanchnic bed results in decreasing portal venous pressure with few serious side effects. MOA Octreotide a synthetic somatostatin analog 50-mcg IV loading dose followed by a 50 mcg/hour continuous IV infusion. Dose combined with endoscopic therapy results in decreased rebleeding rates and transfusion needs when compared with endoscopic treatment alone. Combination Varicies Balloon tamponade Sclerotherapy Therapy should continue for at least 24 to 72 hours after bleeding has stopped. use of balloons inserted into the esophagus, stomach or uterus, and inflated to alleviate or stop refractory bleeding. treatment that use injection of an irritant agents (hypertonic saline, sodium tetradecyl sulfate, polidocanol,..) which cause coagulation of blood and narrowing of the blood vessel wall. It is a non-absorbable sugar used to lower colonic pH, which favors the conversion of ammonia (NH3) to ammonium (NH4 +),which cannot cross back from the gut into the systemic circulation because it is ionic. Lactulose Encephalopathy First line drug therapy Rifaximin usually initiated at 15 to 30 mL two to three times per day. Dose is a non-absorbable antibiotic decreases urease-producing gut bacteria. decreasing ammonia production. used to treat hepatic encephalopathy but are not generally recommended because of toxicity. Antibiotic Metronidazole & Neomycin Prolonged uses of: Metronidazole Neomycin associated with peripheral neuropathy. may lead to nephrotoxicity. Spironolactone also conserves potassium that would otherwise be excreted because of elevated aldosterone levels.