Acute Liver Problems

Transcription

1 Acute Liver Problems Dr. Martin James PhD FRCP Nottingham University Hospitals HST GIM Teaching December 2016

2 Priorities for liver disorders? What will I see on the acute take? Which patients need urgent management? What are the priorities for treatment? What s new in liver disease?

3 Clinical Priorities Decompensated chronic liver disease - 80% Variceal haemorrhage Ascites & infection Encephalopathy Hepatorenal syndrome Acute liver failure - <5% Biliary sepsis - 15%

4 BACKGROUND

5 Lifestyle & liver disease? Alcohol NAFLD Viral Hepatitis

6 Hepatitis C virus (HCV) Annual diagnosis SVR (cure) in Annual Treatment 16, Incidence Annual Cure 2012 Adapted from HPA/Roche 2012

7 New HCV therapies

8 Accessing HCV therapy?

9 Alcohol consumption Caner Research UK 2010

10 Death between years from cirrhosis and other selected diseases: UK Men 30 Women Deaths per man-years Lung cancer Stroke Coronary heart disease Deaths per woman-years Coronary heart disease Breast cancer 0 Cirrhosis 0 Stroke Cirrhosis Year Year Bhala, Foster & Aithal. BMJ 2013

11 Silly Money? Prevention Cure

12 Preventing liver deaths? NHS Atlas of Liver disease 2013

13 WHICH PATIENTS NEED URGENT MANAGEMENT?

14 In-patient jaundice Biliary obstruction Alcohol-related liver disease Other liver diseases, drugs, infection, cancers

15 Clinical Priorities Decompensated chronic liver disease Variceal haemorrhage Ascites & infection Encephalopathy Hepatorenal syndrome Acute liver failure Biliary sepsis

16 Decompensated Cirrhosis Jaundice Bleeding Ascites Encephalopathy Cirrhosis bundle & consider assessment for transplantation Hepatorenal syndrome

17 Cause of decompensation? Sepsis Ascites biliary chest UTI CNS skin GI Bleeding Progression of CLD PV thrombosis Also consider: Head injury Drug ingestion/ toxicity diuretics Electrolytes disturbance Hypoglycaemia Constipation dehydration HCC development DKA, MI etc

18 The golden 24 hours Implementation of the BSG/BASL Decompensated Cirrhosis Care Bundle in acute medicine: NUH local experience feedback P.Thiagarajan, C.Peal, D.Gunn, M.James October 2015

19

20 Chronic Liver Disease by Aetiology 4% Baseline Audit: June % 3% Post-intervention Audit: September % 7% 3% 17% 69% Alcohol Excess, n (%) NAFLD, n (%) Viral Hepatitis, n (%) Autoimmune Unknown 14% 72% Alcohol Excess NAFLD Viral Hepatitis Autoimmune Unknown

21 Cause for decompensation Sepsis, n (%) 23% Upper GI bleeding, n (%) Baseline (n=30) 0% 3% 7% 20% 47% Dehydration, n (%) Drugs, n (%) Hepatocellular carcinoma, n (%) Unknown, n (%) Sepsis, n (%) 24% Upper GI bleeding, n (%) Post-intervention (n=29) 41% Dehydration, n (%) 3% 4% 4% 24% Drugs, n (%) Hepatocellular carcinoma, n (%) Unknown, n (%)

22 Septic Screen Parameters P= P= Percentage % +15% +22% +65% Blood cultures Urine Dipstick CXR Ascitic tap Baseline Post-intervention

23 120.0 Suspected Variceal Haemorrhage P=0.03 P= Percentage % +16% +33% +26% +21% Terlipressin Antibiotics Fluid resuscitation Restrictive Transfusion Lactulose Baseline Post-intervention

24 Bleeding & liver disease Resuscitation Vasopressors and antibiotics Correct coagulation (Platelets <50, INR>1.5, Fibrinogen <1.0) biliary obstruction vs liver failure Identify source of bleeding Endoscopic therapy

25 GI bleeding, antibiotics & mortality Soares-Weiser Cochrane Review 2002

26 Model for Endstage Liver Disease MELD: Bilirubin, PT (INR) and creatinine Gut 2007

27 TIPS for varices Hepatic vein TIPS coils Portal vein

28

29 Early ( 72 hours) TIPS Garcia-Pagan et al NEJM 2010

30 SX-Ella Danis Stent Wright G et al Gastrointestinal Endoscopy 2010

31 Danis Stent

32 Oesophagus post stent removal

33 Secondary prophylaxis oesophageal varices Sharara et al NEJM 2001

34 Diagnostic ascitic tap Sterile Anterior axillary line 50mm cephalic from anterior superior iliac spine Samples for: WCC MC&S (SAAG, cytology)

35

36 Serum-ascitic albumin gradient (SAAG) SAAG serum minus ascitic albumin High SAAG >11g/L LR+ for portal hypertension 4.6 ( ) LR- for portal hypertension 0.06 ( ) Wong JAMA 2008 Gines NEJM 2006

37 Spontaneous bacterial peritonitis (SBP) Increased bacterial translocation in cirrhosis Usually gut organisms High ascitic neutrophils/ WCC (even without organism identified) Sample ascitic fluid aseptically Neutrophils >250/mm 3, Total WCC>500/mm 3 Culture fluid in blood culture bottles.

38 GI bleed PPI? lung ascites urine LN TNFα IL-1 IL-6, IL-8 endotoxin nitric oxide vasodilatation Reduced renal perfusion Resistance C. difficile Hepatorenal syndrome death

39 Cefotaxime vs Cefotaxime & HAS Sort et al NEJM 1999 Outcome Cefotaxime Cefotaxime & 20% albumin p value Infection resolution 94% 98% 0.36 Urea (day 6) Creatinine (day 6) Sodium (day 6) <0.001 MAP (mmhg) Renal failure 33% 10% Mortality In hospital 29% 10% months 41% 22% 0.03

40

41 Clinical Priorities Decompensated chronic liver disease Variceal haemorrhage Ascites & infection Encephalopathy Hepatorenal syndrome Acute liver failure Biliary sepsis

42 Acute liver failure (ALF) Potentially reversible consequence of severe liver injury Encephalopathy within weeks of the onset of first symptoms Absence of pre-existing liver disease

43 Causes of acute liver failure Paracetamol 50% Hepatitis B 10% Hepatitis A/E 5% Other drugs 10% Cryptogenic (non-a, non-b) 20%

44 Drugs associated with liver injury Paracetamol Amoxycillin-clavulinic acid Flucloxacillin Nitrofurantoin Statins Isoniazid Propythiouricil

45 Other causes of ALF Vascular liver diseases Budd Chiari syndrome Ischaemic liver injury Malignant infiltration Autoimmune hepatitis Acute fatty liver of pregnancy Wilson s disease

46 ALT Clinical case

47 Clinical case -ALT Bili PT Albumin

48 Outcome Prediction - KCH criteria Paracetamol ph <7.3 (alone) Or all 3 of: Grade III to IV encephalopathy PT>100 seconds Creatinine >300µmol/L (lactate >3.0 mmol/l after resuscitation) Non-paracetamol Or any 3 of: PT>100 seconds Age <10 or >40 years Bad aetiology (NANB, Drugs) Jaundice to encephalopathy >7 days PT > 50s Bilirubin > 300µmol/L

49 Take home messages -ALF Sick patients; may deteriorate rapidly Resuscitate, assess patient and numbers Transfer to AICU/ liver unit encephalopathy, rising INR, hypotension or ARF, sepsis, hypoglycaemia or bleeding Suspicion of paracetamol; use NAC

50 Transplant indications Gut 2011 Gut 2007

51 Transplant; 5-year survival Gut 2007

52 Clinical Priorities Decompensated chronic liver disease Variceal haemorrhage Ascites & infection Encephalopathy Hepatorenal syndrome Acute liver failure Biliary sepsis

53 Biliary obstruction

54 Management; ascending cholangitis Resuscitation and renal support Check & correct coagulation Biliary drainage Antibiotics (e.g. iv tazoxin, cefuroxime) Organisms: E. Coli, Klebsiella, Streptococcus Analgaesia

55 Relieve obstruction

56 Malignant obstruction

57 Liver abscess

58 Biliary MDT

59 Summary Decompensated liver disease increasing prevention critical treat complications & consider transplantation Acute Liver Failure rare, but early recognition critical Biliary sepsis clinical history, imaging, treat sepsis and achieve drainage MDT approach

60 QUESTIONS?