Liver Disease in Acute Medicine

Transcription

1 Liver Disease in Acute Medicine Jeffrey S Wong July 2012

2 Decompensated Liver Disease Hyponatraemia Variceal bleeding Ascites Management Hepatic Encephalopathy Toms Questions

3 Hyponatraemia in CLD Increasing severity of portal hypertension

4 Hyponatraemia in CLD A case 55 y.o man with known ALD Presents with increasing ascites Medications: Spironolactone 100mg OD, Frusemide 40mg OD Bloods Bili 25, Alb 30 Urea 6, Creatinine 65 Na + 128, K + 4.5

5 What do you do? 1. Discontinue Diuretics 2. Continue Diuretic and Fluid restrict to 1000mL/D 3. Continue Diuretic and further Salt restrict to 44 mmol/d 4. Continue Diuretic and commence saline to correct Na + 5. Increase Diuretic

6 What do you do? 1. Discontinue Diuretics 2. Continue Diuretic and Fluid restrict to 1000mL/D 3. Continue Diuretic and further Salt restrict to 44 mmol/d 4. Continue Diuretic and commence saline to correct Na + 5. Increase Diuretic

7 Diuretics in Hyponatraemia Serum sodium Action > 125 mmol/l No change mmol/l No consensus Rate of fall of sodium Amount of Ascites Renal impairment < 121 mmol/l Stop diuretics Fluid Restrict

8 Hyponatraemia associated with More severe liver disease More frequent SBP Diuretic resistance More frequent HRS Higher mortality

9 Variceal bleeding

10 A case 48 yo man HCV and ALD P/C Haematemesis Pulse 120, BP 110/65 L and 85/55 S Bloods Hb 90, Platelets 75, INR 1.5 Creatinine 100, Urea 25 Bilirubin 55, ALT 30, AST 50, GGTP 345, ALP 100

11 What should be included in the plan? Commence antibiotics Assessment of CPT/MELD score Discussion with Gastroenterology/Hepatology Commence vasoactive drug (Octreotide/Terlipressin) Transfuse to target Hb 100

12 What should be included in the plan?

13 Antibiotics in acute variceal bleeding Acute variceal bleeding in cirrhotics Mortality of 20% Infection rate of 25-50% Cochrane review 2009 Mortality RR reduction 29% (6-46) Infection RR reduction 58% (48-66) Chavez-Tapia Norberto C, Soares-Weiser Karla, Brezis Mayer, Leibovici Leonard. Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. Cochrane Database of Systematic Reviews: Reviews 2009 Issue 1

14 Other Mortality in variceal bleeding best predicted by stage of liver disease using whatever scoring system you are familiar with (CPT/MELD etc..) Vasoactive drugs should be instituted when variceal bleeding is suspected i.e prior to endoscopy and in the case of Terlipressin has been shown to reduce mortality Endoscopy should be performed as soon as possible Diagnosis Control bleeding Risk stratify

15 Ascites Management: A case 65 yo man Background ALD and DCM (EtoH) Ascites Salt restriction Multiple previous LVP Frusemide 500mg Spironolactone 160mg CPT score: A Represents with ascites Findings Pulse 88, BP 105/65 Raised JVP++ Tense ascites Bloods Na + 130, K Creatinine 133

16 What should you do next? Consider peritoneovenous shunt Consider TIPS (Trans jugular porto-systemic shunt) Urinary Na + to assess diuretic effect/compliance Give up and continue LVP with Albumin Carefully increase Spironolactone

17 What should you do next?

18 Notes Peritoneovenous shunts abandoned TIPS contraindicated in heart failure Difficult to assess urinary Na + If high need to be certain of dietary intake If low can indicate poor response or poor compliance Repeated LVP still valid option for many patients Usual Spiro/Frusemide ratio is 100/40 but strategy when coexistent heart failure is not known

19 Hepatic Encephalopathy Hepatic encephalopathy (also known as portosystemic encephalopathy) is the occurrence of confusion, altered level of consciousness, and coma as a result of liver failure Treatments Lactulose Non absorbed antibiotics LOLA (L-ornithine L-aspartate)

20 A case 75 yo woman with cirrhosis secondary to AIH Stable disease Azathioprine with normal ALT Maintenance EVL Emergency laparotomy for SBO without decompensation Presented with AMI Day 3 found comatose No alternative cause found No response to Lactulose Decision to palliate

21 Case continued She then woke up!

22 Tips for care of patients with HE Don t give up Lactulose Use lots of it Use large amount frequently Use rectally if required Do not use low protein diets HE indicates a poor prognosis 1 y survival 42% and 3 y survival 23%

23 Toms Questions Spontaneous Bacterial Peritonitis diagnosis Value of Vitamin K as it never seems to work Terlipressin: When should this be used? TIPS: What is it and what are the indications? Steroids in Alcoholic Hepatitis How much alcohol is required for ALD?

24 Spontaneous bacterial peritonitis Spontaneous Bacterial Peritonitis Culture negative neutrocytic Ascites Mono-microbial nonneutrocytic Bacterascites Neutrophils Culture Other >250 cells/mm 3 Positive >250 cells/mm 3 Negative Indistinguishable from above <250 cells/mm 3 Positive If symptomatic should be treated as above Secondary Bacterial Peritonitis >250 cells/mm 3 Positive (multiple) High LDH Low Glucose

25 Vitamin K In CLD Reduction in both pro and anti-coagulant factors INR only assesses vitamin K dependent pathways At least 25% of CLD patients are Vitamin K deficient Especially in malnourished, EtoH, and Cholestatic CLD Standard tests of coagulation are not predictive of bleeding in patients with Liver Disease Replenishment 10mg i.v OD for three days and then 10mg i.v once per week maintenance

26 Terlipressin Vasopressin (ADH) analogue Most important effects V1a (vasoconstriction) V2 (solute free water reabsorption) Indications Variceal bleeding HRS

27 TIPS (transjugular intrahepatic portosystemic shunt) Radiological placement of a porto systemic stent Reduces portal pressure and it s sequelae Indications Refractory variceal bleeding Refractory ascites

28 Steroids in Alcoholic Hepatitis Should it be used? Maddrey Score Bilirubin Prothrombin time Control Prednisone for score >32 may reduce mortality but Many contraindications Concern re sepsis Higher mortality if score >52 Is it working? Lille score Age day 0 Albumin day 0 Bilirubin day 0 and 7 Creatinine day 0 INR day 0 Survival at 6 months >45 25% <45 85%

29 How much alcohol is too much? How much do you drink Tom?

30 Final words Decompensated CLD patients Are often very complex Are often very unwell if they look fine Are often fine even if they look unwell Have a highly fluctuant course Your mobile device is your friend Scores can be difficult to memorise Should be referred early