June 11, 2015 Tim Halterman

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1 June 11, 2015 Tim Halterman

2 Defini&on Histologic change + loss of liver function Derives from Greek word kirrhos meaning yellow, tawny First named by Rene Laennec in 1819 Laennec s cirrhosis=alcoholic cirrhosis

3 Histologic changes

4 Other clues to diagnosis Physical exam stigmata Lab data Typical transaminase pattern Liver function tests Platelets Imaging studies Nodular liver, enlarged caudate lobe, enlarged portal vein, splenomegaly Ultrasound: sensitivity 30-89%, specificity % CT and MRI

5 Portal Hypertension Definition Hepatic venous pressure gradient (HVPG) >8

6 Portal Hypertension Causes Pre- hepatic (pre- sinusoidal) Intra- hepatic (sinusoidal) Post- hepatic (post- sinusoidal)

7 Complica&ons of Cirrhosis Varices (esophageal and gastric), portal hypertensive gastropathy Any melena, hematochezia, hematemesis? Ascites Any abdominal or leg swelling or significant weight gain? Hepatic encephalopathy Any confusion or difficulty thinking, trouble sleeping? Hepatocellular carcinoma

8 Esophageal Varices Rationale for screening Screening recommendations All patients with cirrhosis should undergo EGD Surveillance of esophageal varices Compensated cirrhosis and no varices on initial EGD Repeat EGD 2-3 years Decompensated cirrhosis Repeat EGD yearly unless already on prophylaxis Repeat EGD at first sign of decompensation

9 Esophageal varices Grading of varices: small versus large

10 Esophageal Varices Primary prophylaxis Small varices without red wale sign: no prophylaxis Small varices with red wale sign or Childs class B/C cirrhosis: endoscopic variceal ligation (EVL), nonselective beta- blocker Large varices: endoscopic variceal ligation (EVL) or non- selective beta- blocker Beta- blocker versus EVL

11 Esophageal varices Management of bleeding varices General measures: IV access, airway issues, resuscitation goals, antibiotics Pharmacologic therapy: octreotide Endoscopic therapy: EVL versus sclerotherapy Combination therapy: EVL + octreotide BEST strategy Recurrent bleeding: TIPS, Minnesota tube

12 Esophageal Varices Secondary prophylaxis Recurrent EVL + nonselective beta- blocker PPI twice daily to prevent post- banding ulcers

13 Gastric Varices Primary prophylaxis Nonselective beta- blockers Management of acute bleeding Cyanoacrylate injection versus TIPS EVL for GOV1 varices

14 Ascites Most common complication of cirrhosis 15% of pts with ascites die within one year, 45% within 5 years Causes Cirrhosis- 85% Liver related without cirrhosis: acute alcoholic hepatitis, Budd- Chiari, acute liver failure Other: cardiac, nephrotic syndrome, malignant, TB, pancreatitis, chylous

15 Ascites Paracentesis should be performed in any patient with new onset ascites, either inpatient or outpatient Paracentesis should be performed on any inpatient with symptoms suggestive of SBP, worsened renal function, encephalopathy, hypotension, hypothermia or acidosis

16 Ascites Routine peritoneal fluid tests Serum albumin ascites gradient Cell count and diff Albumin and total protein Specialized peritoneal fluid tests Cytology Amylase Triglycerides AFB bilirubin

17 Ascites Treatment Low sodium diet <2 grams per day Diuretics Spironolactone alone Spironolactone + furosemide Ratio of 100 mg spironolactone & 40 mg furosemide daily Max dose of 400 mg spironolactone & 160 mg furosemide Fluid restrict only if Na less than 125

18 Refractory ascites Management Large volume paracentesis If remove >5L, recommend albumin infusion TIPS Liver transplant Avoidance of non- selective beta- blockers, ACE/ARB, NSAIDs Midodrine

19 SBP Diagnosis 250 PMNs/mm 3 Culture negative v culture positive Treatment Third generation cephalosporin (preferably cefotaxime) for 5 days Oral ciprofloxacin for 7 days Albumin: 1.5 mg/kg day 1 and 1 mg/kg day 3 Conditions that require more broad- spectrum abx

20 SBP Prophylaxis Who benefits? History of SBP Low protein ascites (protein <1.5) + Cr >1.2 or bili >3 or Na <130 What to use? Norfloxacin 400 mg daily or cipro 500 mg daily Bactrim DS daily Cipro 750 mg weekly- not as effective PPIs and SBP

21 Hepatorenal Syndrome Diagnosis cirrhosis with ascites serum creatinine greater than 1.5 mg/dl no improvement of serum creatinine (decrease to a level of 1.5 mg/dl or less) after at least two days with diuretic withdrawal and volume expansion with albumin absence of shock no current or recent treatment with nephrotoxic drugs absence of parenchymal kidney disease Urinary neutrophil gelatinase- associated lipocalin

22 Hepatorenal Syndrome Treatment Albumin + midodrine/octreotide Albumin + norepinephrine (ICU patients) Liver transplant

23 Hepa&c encephalopathy West Haven grading criteria (Overt) Grade 1 - Trivial lack of awareness; euphoria or anxiety; shortened attention span; impaired performance of addition or subtraction Grade 2 - Lethargy or apathy; minimal disorientation for time or place; subtle personality change; inappropriate behaviour Grade 3 - Somnolence to semistupor, but responsive to verbal stimuli; confusion; gross disorientation Grade 4 - Coma (unresponsive to verbal or noxious stimuli) Minimal hepatic encephalopathy and covert HE

24 Hepa&c encephalopathy Altered sleep- wake cycle Physical Exam findings: asterixis, hyperreflexia Ammonia levels Remember to think about precipitants

25 Hepa&c encephalopathy Management Lactulose Titrate to 3 loose BMs per day Nonabsorbable antibiotics Xifaxin 550 mg twice daily- typically add on therapy Neomycin Metronidazole Others: zinc, BCAA, acarbose,?probiotics No benefit to protein restriction

26 Hepatocellular carcinoma Screening Good quality US every 6 months AFP not recommended by AASLD but supported by many experts CT/MRI not cost effective Who to screen? Anyone with cirrhosis Chronic hepatitis B- Asian M >40, Asian F >50, FHx, Africans >25 Uncertain benefit: HCV stage 3 fibrosis, NAFLD

27 Hepatocellular carcinoma Screening recommendations

28 AASLD Guidelines

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