Tuesday, July 22, 2008

Day #22 - Advanced Cirrhosis

Today we had an expert hepatologist come to talk with us about a case of a patient with cirrhosis, chronic hepatitis B, and hepatocellular carcinoma. Many things were discussed but I wanted to touch upon a few regarding the complications of chronic liver disease and treatment thereof.

The discussant divided the complications into those related to portal hypertension and those not related to portal hypertension. This is a useful framework.

Remember, if you can stop the process that is damaging the liver (ETOH, HBV, HCV) you may be able to make a big difference in patient outcomes.

Portal HTN related:

Varices - Esophogeal, Gastric
  • Avoidance (if possible) of NSAIDs
  • Surveilance OGD q2 years if no varices, q1 year if low grade varices, more frequently if high grade varices or bleeding
  • Endoscopic therapy (banding): For those with high grade varices or those who have bled (may not be superior to pharmacotherapy).
  • Pharmacotherapy: non-selective beta-blockers +/- isosorbide mononitrate for patients with known varices and those who have bled
  • Combination of both endoscopic therapy and pharmacotherapy may be the best for primary and secondary prophylaxis
Ascites
  • Fluid and Salt Restriction
  • Diuretics: spironolactone and furosemide (oral) in dose ratio of 100:40 titrated to effect. Goal is to increase 24h sodium excretion above intake
  • Therapeutic Paracentesis
  • TIPS
SBP - See Day #18

Splenomegaly and hypersplenism

Hepatorenal or Hepatopulmonary syndromes

Non-Portal Hypertension Related:

Encephalopathy
  • Avoidance of precipitating medications (benzos, narcotics) and foods (e.g. high protein load)
  • Recognizing precipitants -- GI bleeding, infection, renal failure, hypokalemia
  • Protein restriction
  • Lactulose -- Often used with little evidence
  • Antibiotics -- RIFAMIXIN
Synthetic Dysfunction -- Supportive care

Hepatoma:
  • Risk Factors:
    HBV, HCV, FHx, Toxin Exposure, (?smoking)
  • Screening: Ultrasound +/- AFP on an annual basis for those with high risk features
  • Early treatment



We also talked about the Child-Pugh and MELD scores as prognostic aids and tools for selecting patients for transplantation referral.

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