Liver Failure AM anagement Guide13032007

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Liver Failure AM anagement Guide13032007 Powered By Docstoc
					            Dr Allister J Grant
        Consultant Hepatologist
University Hospitals Leicester NHS Trust
   Anatomy &Physiology
                            IVC




                          Portal Vein


                          Hepatic Artery


                          Splenic Vein


Gallbladder   CBD   SMV
Anatomy &Physiology
         Liver Functions
Nutrition/Metabolic
  – stores glycogen (glucose chains)
  – releases glucose
  – absorbs fats, fat soluble vitamins
  – manufactures cholesterol

Bile Salts
   – lipids derived from cholesterol
   – dissolves dietary fats (detergent)

Bilirubin
   – breakdown product of haemoglobin
         Liver Functions
Clotting Factors
  – manufactures most clotting factors

Immune function
  – Kupfer cells engulf antigens (bacteria)

Detoxification
 – drug excretion (sometimes activation)
 – alcohol breakdown

Manufactures Proteins
  – albumin
  – binding proteins
             Disease Progression
Acute Liver Failure       Chronic Liver Disease

• <6 weeks duration       • >6 months

•   Jaundice              Cirrhosis leading to
•   Encephalopathy
•   Cerebral Oedema       • Recurrent decompensation
•   Acute Renal Failure       – Ascites
•   Acidosis                  – Portal Hypertension (variceal
                                bleeding)
•   Hypoglycaemia
                              – Encephalopathy
•   MOF
                          •   Low albumin/Malnutrition
                          •   Hepatorenal syndrome
                          •   Hyponatraemia
                          •   Hepatoma
                       Disease Progression

100%
                                                 A
  Liver function




                                                 B



                                                     Cirrhosis



                                                 Liver Failure

                   D                 Years   C
       24♀ 48hours post POD
• ALT 13000      •   Ph 7.1
• Alb 35         •   PCO2 3.2
• Bili 40        •   PO2 12.4
                 •   BE -6
• Cr 160
• Urea 24

• INR 3.0
• PT 33

• Glc 3.6
                           ALF
•   Treat the underlying cause
•   Resuscitate - Central access early
•   Give N-Ac regardless of cause
•   Monitor for hypoglycaemia
•   Monitor coagulopathy
•   Antibiotic prophylaxis
•   Stress Ulcers
•   Early elective ventilation for encephalopathy
•   Nutrition
•   Acidosis/ Renal Impairment

• Early referral to Hepatology / discuss with Birmingham Liver
  Unit
                         Mrs W
• 48 year old ♀ admitted from a surgical clinic with
  jaundice and unwell

• Unwell for 6 wks after holiday in Mexico

• Hx of xs alcohol 30u/wk

• No previous jaundice

• USS normal size liver and spleen – biliary tree normal
                       OE

• Jaundice
• Drowsy
                            No spleen
• Agitated/Irritable        No ascites
• Doesn’t obey
  commands
• No stigmata of CLD
• Asterixis
                    Mrs W
• U&E      normal      • FBC   Normal

•   ALP    107         • INR   3.7
•   ALT    736
•   Bili   363
•   Alb    24
   Causes of Acute Liver Failure
• Drugs                 • Wilsons Disease
   • Paracetamol (UK)
   • INH                • Autoimmune Hepatitis
   • Halothane
   • Ecstacy            • Reye’s Syndrome

• Viral                 • Cardiovascular
   • Hepatitis A           • Ischaemic hepatitis
   • Hepatitis B           • Budd Chiari
   • Hepatitis E
   • Non-A Non-B        • Acute Fatty Liver of Pregnancy
                Encephalopathy
• Grade 1
            »   Constructional apraxia
            »   Poor memory – number connection test
            »   Agitation/ irritability
            »   Reversed sleep pattern
• Grade 2
            » Lethargy, disorientation
            » Asterixis
• Grade 3
            » Drowsy, reduced conscious level
• Grade 4
            » Coma
  Cirrhosis



Expanded Portal Tracts
       (Blue)
Signs of Chronic Liver Disease

 • None
 • Asterixis/Flap
 • Relative hypotension
 • Oedema
 • Jaundice/No jaundice
 • Large/Small liver
 • Splenomegaly
 • Gynecomastia
 • Testicular atrophy-loss of secondary sexual
                     characteristics
 • Impotence
Decompensation in Cirrhosis

       Means the development of-

                 Ascites

         Hepatic Encephalopathy

 Portal hypertension (variceal haemorrhage)
Decompensation in Cirrhosis

       Means the development of-

                 Ascites

         Hepatic Encephalopathy

 Portal hypertension (variceal haemorrhage)
   The Development of Ascites

50% of compensated
cirrhotics develop
ascites over 10yrs

50% of cirrhotics with
ascites will die within 2
yrs

(50% 2yr rule for OLTx
assessment)
  The Development of Ascites
Peripheral arterial dilatation


Reduced effective blood volume


Activation of renin-angiotensin-aldosterone system
Sympathetic nervous system
ADH                               NaCl

Na retention                     Ascites and Oedema
   &                             Low urinary Na
Water retention                  Dilutional hyponatraemia

Plasma volume expansion

Ascites
                                                       Schrier et al Hepatol 1988
 General Management
Ascites and Oedema

• Salt restriction

• Diuretics
                 spironolactone
                 frusemide

• Water restriction if sodium < 125 mmol

• Paracentesis
                 diagnostic (SBP, tumour)
                 therapeutic (20% Alb)

• DAILY WEIGHTS!
Decompensation in Cirrhosis

       Means the development of-

                 Ascites

         Hepatic Encephalopathy

 Portal hypertension (variceal haemorrhage)
      Causes of Encephalopathy
INCREASED AMMONIAGENESIS

      Increased substrate (protein) for ammoniagenesis

  –   Increased protein intake
  –   Gastrointestinal bleeding
  –   Constipation
  –   Dehydration

      Increased substrate (urea) for ammoniagenesis

  – Renal failure

      Increased catabolism of protein

  – Infection
  – Hypokalemia
  – Sepsis
      Causes of Encephalopathy
DECREASED HEPATOCELLULAR FUNCTION

  –   Worsened intrinsic liver disease
  –   Hypoxia
  –   Anaemia
  –   Development of hepatocellular carcinoma
  –   Dehydration
  –   Hypotension
  –   Sepsis
  –   Drug toxicity
  –   Superimposed viral hepatitis
Causes of Encephalopathy
INCREASED PORTOCAVAL SHUNTING

  –   Portal vein thrombosis
  –   Transjugular intrahepatic portosystemic shunt formation
  –   Surgical shunt formation
  –   Spontaneous shunt formation

PSYCHOACTIVE DRUG USE

  –   Benzodiazepines
  –   Ethanol
  –   Antiemetics
  –   Antihistamines
  –   Others
General Management
Encephalopathy

Minimize effects of liver disease

Treat precipitants
        • sepsis
        • GI bleed
        • medications (over-diuresis)

Avoid sedatives, hypnotics, opiates

Lactulose to ensure BO 2x/day

Metronidazole/ neomycin
Decompensation in Cirrhosis

       Means the development of-

                 Ascites

         Hepatic Encephalopathy

 Portal hypertension (variceal haemorrhage)
  Portal
Circulation
Oesophageal varices
Management of Bleeding Varices
• Prevention

• Prophylactic Antibiotics

• Resuscitation

• Endoscopy -       Band Ligation
                    Sclerotherapy

• Pharmacotherapy- Terlipressin

• Balloon Tamponade

• TIPS
Management of Bleeding Varices
• Prevention

• Prophylactic Antibiotics

• Resuscitation

• Endoscopy -       Band Ligation
                    Sclerotherapy

• Pharmacotherapy- Terlipressin

• Balloon Tamponade

• TIPS
        Fluid Management

•   Crystalloid
•   Colloid
•   Blood
•   Platelets
•   FFP
•   Vitamin K
Management of Bleeding Varices
• Prevention

• Prophylactic Antibiotics

• Resuscitation

• Endoscopy -       Band Ligation
                    Sclerotherapy

• Pharmacotherapy- Terlipressin

• Balloon Tamponade

• TIPS
Oesophageal varices
Bleeding Gastric Varices
Variceal Bander
Variceal Band Ligation
Management of Bleeding Varices
• Resuscitation

• Endoscopy -     Band Ligation
                  Sclerotherapy

• Pharmacotherapy-     Terlipressin 2mg qds i.v

• Balloon Tamponade

• TIPS
Management of Bleeding Varices
• Resuscitation

• Endoscopy -     Band Ligation
                  Sclerotherapy

• Pharmacotherapy- Terlipressin

• Balloon Tamponade

• TIPS
Sengstaken-Blakemore Tube
Complication of SBT
Management of Bleeding Varices
• Resuscitation

• Endoscopy -     Band Ligation
                  Sclerotherapy

• Pharmacotherapy- Terlipressin

• Balloon Tamponade

• TIPS
             The End
            “All right, let's not panic.
I'll make the money by selling one of my livers.
             I can get by with one “




                    Doh!

				
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posted:2/28/2012
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