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Complications of Liver Complications of Liver CirrhosisCirrhosis
Ayman Abdo Ayman Abdo MD, AmBIM, FRCPCMD, AmBIM, FRCPC
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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
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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
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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
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Anatomy of the portal venous systemAnatomy of the portal venous system
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The Effect of The Liver NoduleThe Effect of The Liver Nodule
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Mechanism of Portal HTNMechanism of Portal HTN
Cirrhosis
Resistance portal flow
MechanicalNodules
DynamicNitric oxide
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Complications of Portal Complications of Portal HypertensionHypertension
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1. Varices1. Varices
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CollateralsCollaterals
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VaricesVaricesEsophagusEsophagus
GastricGastric
Colo-rectalColo-rectal
Portal hypertensive gastropathyPortal hypertensive gastropathy
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VaricesVaricesDiagnosisDiagnosis
History : Hematemases, melenaHistory : Hematemases, melena
Physical examinationPhysical examination
Ultrasound abdomenUltrasound abdomen
EndoscopyEndoscopy
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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)
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VaricesVaricesManagement-SpecificManagement-Specific
IV vasoconstrictors (Octreotide)IV vasoconstrictors (Octreotide)
Endoscopic therapyEndoscopic therapy
BandingBanding
SclerotherapySclerotherapy
ShuntingShunting
SurgicalSurgical
TIPSTIPS
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Variceal BandingVariceal Banding
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Types of ShuntsTypes of Shunts
TIPS (Transjugular intrahepatic portosystemic shunt)
Surgical shunt
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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
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2. Ascites2. Ascites
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AscitesAscites
Definition: fluid in the Definition: fluid in the peritonial cavityperitonial cavity
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Mechanism of AscitesMechanism of Ascites
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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
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PresentationPresentationHistory:History:
Increased abdominal girthIncreased abdominal girthIncreased wtIncreased wt
Physical exam:Physical exam:Bulging flanksBulging flanksShifting dullnessShifting dullnessFluid waveFluid wave
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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
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Portal hypertension
or heart failure
Peritonial disease
or kidney disease
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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))
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Treatment-ResistantTreatment-ResistantRecurrent tappingRecurrent tapping
Peritoneal-venous shuntPeritoneal-venous shunt
TIPS TIPS
Liver transplantationLiver transplantation
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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
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3. Hepatic 3. Hepatic EncephalopathyEncephalopathy
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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
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Hepatic EncephalopathyHepatic EncephalopathyMechanismMechanism
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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
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Flapping TremorFlapping Tremor
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Drawing TestsDrawing Tests
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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
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Hepatic EncephalopathyHepatic EncephalopathyExacerbating factorsExacerbating factors
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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
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4. Hepatorenal 4. Hepatorenal SyndromeSyndrome
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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
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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
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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