Complications of Liver Complications of Liver CirrhosisCirrhosis

Ayman Abdo Ayman Abdo MD, AmBIM, FRCPCMD, AmBIM, FRCPC

ObjectivesObjectives1.1. Understand the basic mechanisms Understand the basic mechanisms

of portal hypertensionof portal hypertension

2.2. Recognized the classic Recognized the classic presentations of portal hypertension presentations of portal hypertension complicationscomplications

3.3. Get an idea on the management of Get an idea on the management of these complicationsthese complications

What is Liver Cirrhosis?What is Liver Cirrhosis?

Diffuse fibrosis of the liver with Diffuse fibrosis of the liver with nodule formationnodule formation

Abnormal response of the liver to Abnormal response of the liver to any chronic injuryany chronic injury

Causes of CirrhosisCauses of Cirrhosis1.1. Chronic viral hepatitisChronic viral hepatitis2.2. Metabolic: hemochromatosis, Wilson dis, Metabolic: hemochromatosis, Wilson dis,

alfa-1-antitrypsin, NASHalfa-1-antitrypsin, NASH3.3. Prolonged cholestasis (primary biliary Prolonged cholestasis (primary biliary

cirrhosis, primary sclerosing cholangitis)cirrhosis, primary sclerosing cholangitis)4.4. Autoimmune diseases (autoimmune Autoimmune diseases (autoimmune

hepatitis)hepatitis)5.5. Drugs and toxinsDrugs and toxins6.6. AlcoholAlcohol

Anatomy of the portal venous systemAnatomy of the portal venous system

The Effect of The Liver NoduleThe Effect of The Liver Nodule

Mechanism of Portal HTNMechanism of Portal HTN

Cirrhosis

Resistance portal flow

MechanicalNodules

DynamicNitric oxide

Complications of Portal Complications of Portal HypertensionHypertension

1. Varices1. Varices

CollateralsCollaterals

VaricesVaricesEsophagusEsophagus

GastricGastric

Colo-rectalColo-rectal

Portal hypertensive gastropathyPortal hypertensive gastropathy

VaricesVaricesDiagnosisDiagnosis

History : Hematemases, melenaHistory : Hematemases, melena

Physical examinationPhysical examination

Ultrasound abdomenUltrasound abdomen

EndoscopyEndoscopy

VaricesVaricesManagement-GeneralManagement-General

ABCABC2 IV Lines2 IV LinesType and cross matchType and cross matchResuscitationResuscitation

IVFIVF BloodBlood

Platelet transfusion (platelet <75,000)Platelet transfusion (platelet <75,000)Fresh frozen plasma (Correct Pt)Fresh frozen plasma (Correct Pt)

VaricesVaricesManagement-SpecificManagement-Specific

IV vasoconstrictors (Octreotide)IV vasoconstrictors (Octreotide)

Endoscopic therapyEndoscopic therapy

BandingBanding

SclerotherapySclerotherapy

ShuntingShunting

SurgicalSurgical

TIPSTIPS

Variceal BandingVariceal Banding

Types of ShuntsTypes of Shunts

TIPS (Transjugular intrahepatic portosystemic shunt)

Surgical shunt

VaricesVaricesPreventionPrevention

Treat underlying diseaseTreat underlying disease

Endoscopic banding protocolEndoscopic banding protocol

B-blockersB-blockers

Shunt surgery (only if no Shunt surgery (only if no cirrhosis)cirrhosis)

Liver transplantationLiver transplantation

2. Ascites2. Ascites

AscitesAscites

Definition: fluid in the Definition: fluid in the peritonial cavityperitonial cavity

Mechanism of AscitesMechanism of Ascites

Causes of AscitesCauses of Ascites1.1. Liver disease: cirrhosisLiver disease: cirrhosis

2.2. Right sided heart failureRight sided heart failure

3.3. Kidney disease (nephrotic syndrome)Kidney disease (nephrotic syndrome)

4.4. Low albumin (malnutrition, bowel loss)Low albumin (malnutrition, bowel loss)

5.5. Peritonial infection (TB…)Peritonial infection (TB…)

6.6. Peritonial cancerPeritonial cancer

PresentationPresentationHistory:History:

Increased abdominal girthIncreased abdominal girthIncreased wtIncreased wt

Physical exam:Physical exam:Bulging flanksBulging flanksShifting dullnessShifting dullnessFluid waveFluid wave

DiagnosisDiagnosisPhysical examinationPhysical examinationUltrasoundUltrasoundAscitic tapAscitic tap

WBC (>250 PMN: SBP)WBC (>250 PMN: SBP)RBCRBCSAAG (serum albumin to ascitic fluid albumin SAAG (serum albumin to ascitic fluid albumin

gradient)gradient)>11 mg/dl : portal hypertension>11 mg/dl : portal hypertension<11 mg/dl : Other<11 mg/dl : Other

Portal hypertension

or heart failure

Peritonial disease

or kidney disease

Treatment-GeneralTreatment-GeneralTreat the underlying diseaseTreat the underlying disease

Salt restriction (<2gm/d)Salt restriction (<2gm/d)

DiureticsDiuretics

Loop diuretic (Lasix)Loop diuretic (Lasix)

Aldosterone inhibitor (SpironolactoneAldosterone inhibitor (Spironolactone))

Treatment-ResistantTreatment-ResistantRecurrent tappingRecurrent tapping

Peritoneal-venous shuntPeritoneal-venous shunt

TIPS TIPS

Liver transplantationLiver transplantation

Spontaneous Bacterial PeritonitisSpontaneous Bacterial Peritonitis

Infection of ascitic fluidInfection of ascitic fluid

Usually gram negative (E.Coli)Usually gram negative (E.Coli)

Presentation variablePresentation variable

Mortality is highMortality is high

Dx: ascitic tap = PMN>250Dx: ascitic tap = PMN>250

Treatment : third generation Treatment : third generation cephalosporin IVcephalosporin IV

3. Hepatic 3. Hepatic EncephalopathyEncephalopathy

Hepatic Hepatic EncephalopathyEncephalopathy

Reversible decrease in Reversible decrease in neurological function secondary to neurological function secondary to liver diseaseliver disease

Acute: seen with acute liver Acute: seen with acute liver failurefailure

Acute on chronic: established Acute on chronic: established cirrhosiscirrhosis

Hepatic EncephalopathyHepatic EncephalopathyMechanismMechanism

Hepatic EncephalopathyHepatic EncephalopathyClinical featuresClinical features

Reversal of sleep patternReversal of sleep pattern

Disturbed consciousnessDisturbed consciousness

Personality changesPersonality changes

Intellectual deteriorationIntellectual deterioration

Fetor hepaticusFetor hepaticus

AstrexisAstrexis

FluctuatingFluctuating

Flapping TremorFlapping Tremor

Drawing TestsDrawing Tests

Hepatic EncephalopathyHepatic EncephalopathyDiagnosisDiagnosis

Clinical (most important)Clinical (most important)

The drawing testsThe drawing tests

EEG EEG

CT/MRI may show cerebral atrophyCT/MRI may show cerebral atrophy

Hepatic EncephalopathyHepatic EncephalopathyExacerbating factorsExacerbating factors

Hepatic EncephalopathyHepatic EncephalopathyTreatmentTreatment

Identify and treat precipitation factorIdentify and treat precipitation factor

Treat underlying liver diseaseTreat underlying liver disease

Normal protein dietNormal protein diet

Antibiotics (Neomycin, metronidazole)Antibiotics (Neomycin, metronidazole)

LactoloseLactolose

TransplantationTransplantation

4. Hepatorenal 4. Hepatorenal SyndromeSyndrome

Hepatorenal SyndromeHepatorenal SyndromeProgressive renal failureProgressive renal failure

Type 1 : rapidly progressive, high Type 1 : rapidly progressive, high mortalitymortality

Type 2: slower progressionType 2: slower progression

R/O volume depletion secondary to R/O volume depletion secondary to diureticsdiuretics

IV vasoconstrictorsIV vasoconstrictors

Liver transplantationLiver transplantation

SummarySummary1.1. Mechanical compression of blood flow Mechanical compression of blood flow

plus hemodynamic changes leads to plus hemodynamic changes leads to portal hypertensionportal hypertension

2.2. Common complications of portal Common complications of portal hypertension are:hypertension are:

Collateral formation (Varices)Collateral formation (Varices)

AscitesAscites

Hepatic encephalopathyHepatic encephalopathy

SummarySummary3. The most important step in variceal bleed 3. The most important step in variceal bleed

management is resuscitationmanagement is resuscitation

4. The most important step in management 4. The most important step in management of hepatic encephalopathy is the of hepatic encephalopathy is the identification of the precipitating factoridentification of the precipitating factor