CIRRHOSIS AND ITS COMPLICATIONS
Dr TrÇn Ngäc ¸nh Hanoi Medical University
Causes : Hepatitis B, Hepatitis C,
Alcoholism, Hemochromatosis
Major complications: Spontaneous bacterial
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peritonitis, Variceal hemorrhage, Hepatic
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encephalopathy, Hepatorenal syndrome,
HCC
Child Pugh: prognostic, hemorrhage,
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operative mortality
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Objective 1.Recognize the typical clinical presentation and
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risk factor for Cirrhosis
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2.Understand pathophysiology of Cirrhosis
focusing on alcohol, viral hepatitis
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3.Describe an appropriate diagnostic plan 4.Prescribe an appropriate therapeutic regime: No complication and With complication
DIAGNOGIS
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COMPLICATIONS
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MANAGEMENT
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GENERAL
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1.1.Definition - ‘Cirrhosis’: is derived from the
Greek kirrhos-meaning orange or twany, +osis meaning condition -Cirrhosis is common end result
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of many chronic liver disordes: Diffuse scarring of liver-follows hepatocellular necrosis of hepatitis. Inflammation healing with fibrosis. Regenerations of remaining hepatotcytes from regenerating nodules. Loss of normal architecture and function
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-Cirrhosis extensive fibrosis with loss of architecture, scaring with regenarating nodules (liver failure). -WHO: a diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules which lack normal
GENERAL
Hepatitis chronic Cirrhosis HCC
Lobule, Portal triad
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GENERAL
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1.2.Classification 1.2.1.Morphologic: -micronodular (<3mm):
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alcoholism, hemochromatosis, -macronodular(>3mm):
Chronic viral hepatitis, deficit 1antitrypsin, PBC
-mixed: 1.2.2.Etiologic: Alcholism Chronic viral hepatitis
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GENERAL
Disse
Disse
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GENERAL
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1.3.Causes 1.3.1.Chronic viral hepatitis: B,C,D, 1.3.2.Alcoholism 1.3.3.Inherited metabolic liver disease: Hemochromatosis,
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Wilson, alpha 1antitrypsin deficiency, Cystic fibrosis
1.3.4.Biliary cirrhosis -Primary biliary cirrhosis -Primary sclerosing cholangite -Autoimmune cholangiopathy.. 1.3.4.Autoimmune hepatitis, 1.3.5.Nonalcoholic steatohepatitis 1.3.6.Cardiac cirrhosis 1.3.6.Cryptogenic fibrosis
DIAGNOSTIC
2.1.Clinical features: nonspecific,
more specific complication
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2.1.1.Syndrome of
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Hepatocellular failure:
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-Anorexia, malaise, muscle
wasting,
-Vague right upper quadrant
pain,
-Fever, nausea, vomiting,
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diarrhea
DIAGNOSTIC
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-Encephalopathy: flapping- asterixis, confusion, fetor hepaticus
-Dermatiologic: palma erythema, Spider angiomas, Nail change, Dupuytren’s contractures, Jaundice
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-Endocrine: Hypognadism,
parotid gland enlargement, Digital clubbing
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Vang da
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Spider angiomas
Palmar erythema
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DIAGNOSTIC
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►Syndrome of Portal hypertension -Splenomegaly, -Abdominal varice, Caput medusa -Syndrome Cruveilhier Baugramten, -Varicela hemorrhage ►Ascites -SAAG> 1,1g/dL AFTP<2,5 g/dL -High risk: Alocoholism, HCC, Hemorrhage, Infection,
Diuretic
►Hepatomegaly: dur, ►Others: Alcoholism, bilateral parotid enlargement,
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Scanty chest, axillary hair
Ascites/Cirrhosis
Paracentesis
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Caput medusa
Abdominal varice
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DIAGNOSTIC
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2.2.Laboratory evaluation 2.2.1.Liver function test ►Test of hepatocellular necrosis: AST, ALT , LDH↑ ►Test of cholestase: BR , PA, GGTIP↑ ►Test of synthetic function: TP , Albumin↓ 2.2.2.Specila test to aid in diagnosis ►Viral hepatitis serology ►Ceruloplasmin, Autoantibodies, Iron, TIBC AFP, 2.2.3.Endoscopy: ►Varice. ►Gastropathy
Varice gastric
Gastropathy
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Gastropathy
Varice gastric: red spot
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Grade 2
Grade1
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Độ 3 Varrice hemomrrhage- Grade 3
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Ultrasoud of abdominla
CT abdominal
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2.3.Imaging modalitiees ►Abdominal ultrasound: -KÝch thước, irregular, detect
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- Splenomegayl, Portal
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ascites, HCC;
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vein>12mm,
►CT : may be helpful in diagnosis hemochromatosis ►MRI: suspicious liver lesions,
hepatic vasculature
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2.4.Liver biopsy: gold standard
Chronic liver failure+Portal hypertension=Cirrhosis
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Chronic liver failure
Hepatomegaly +Liver biopsy=Cirrhosis
Portal hypertension+ Liver biopsy=Cirrhosis
+Liver biopsy=Cirrhosis
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PROGNOSIS
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Hemorrhage
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HCC
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Spontaneus bacterial peritonitis
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Encephalopathy
Hepatorenal syndrome
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COMPLICATIONS
3.1.SBP: Ascitic fluid culture+; PN count in ascites
>250cells/mm3
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3.2.Varriceal hemorrhage: 25-35% patients
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433.Encephalopathy: Neuropsychiatric signs/ patients with
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significant liver disfunction
3.4.HCC: Abdominal ultrasound, AFP/3 months
3.5.Hepatorenal syndrome:
Major criteria: CLD with advanced hepatic failure; Creatinin>
1,5mg/dL, Creatinin clearance< 40ml/min
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Additional criteria: Urine<500ml/24h, Na urine<10mEq/L, Na serum
<130mEq/L
Varice oesophagus
Varice gastric
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Treatment
symptoms
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Etiological
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Treatment
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Treatment
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complications
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Transplantation
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MANAGEMENT
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4.1.Specific treatments -Hemochromatosis: Phlebotomy -BÖnh Wilson: D-penicillamine -Cirrhsos alcohol: alcohol avoidance -Antiviral agents: IFN, Nucleotides 4.2.In most cases –treatment of complications 4.2.1.Ascite ►Ascite -Identify possible precipating factors: Dietary, Hemorrhage,
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HCC, NSAID, Medical, Infection, Thrombosis
-No added salt diet: 2g-88mEq/24 h -Stepwise diuretic approach + Spironolactone, Canrenone: maximum 400mg + Spironolactone +Furosemide most effective
MANAGEMENT
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►Refractory ascites -Water <500ml/24 giê -Large volume paracentesis -TIPS, Liver transplantaion 5.2.2.Spontaneous bacterial peritonitis : -Antibiotic : Augmentin, Cephalosporin, Cefotaxim / 2-3
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-Large volume paracentesis -Stop diuretic -Liver transplantation
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4.3.Gastrointestinal bleeding -Endoscopy: Sclerose, EVL -Ballon tamponade -Pharmacologic therapy: Vasopressine, Somatostatin,
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Sandostatin, Glypressin
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-TIPS, Surgery 4.4.Hepatic encephalopahty -Rule out other causes of encephalopahy -Identify precipating factors -Empirical treatment: Lactulose, Antibiotic 4.5.Screening for HCC: Ultrasound, AFP/ 3 months 4.6.In the end stage cirrhosis ; Orthotopic liver
transplantation
Tiêm xơ TMTQ
Thắt TMTQ
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Sonde Blackemore
Sonde Blackemore
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GASTROINTESTINAL BLEEDING
Invasive
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Non invasive
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Endoscopy
TIPS
Drug
Surgery
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TIPS
TIPS
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