Hepatology cases for the generalist. Will Gelson Consultant Hepatologist Addenbrooke s Hospital
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1 Hepatology cases for the generalist Will Gelson Consultant Hepatologist Addenbrooke s Hospital
2 30 y o man with upper GI haemorrhage Background heavy alcohol use Hxof 3 pint haematemesis P 100, BP 90/40, pale Hb90, Plt70, PT 17, bili100, alb30
3 Most likely diagnosis? 1. Peptic ulceration 2. Varicealhaemorrhage
4 Most important initial management 1. Endoscopy 2. Volume resuscitation with colloid/crystalloid 3. Volume resuscitation with blood 4. Terlipressin
5 Progress Difficult to stabilise Goes onto have large volume haematemesis Do you: 1. Call ITU 2. Call endoscopy 3. Call both
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7 Supportive treatment Endoscopic therapy Abx Terlipressin Supportive measures Sengstakentube/ Danis stent TIPSS
8 35 y o lady with acutely deranged LFT Clinical history: Usually fit and well History of heavy alcohol use Blood tests on arrival INR 24.9 ALT 8522 Creat219 Bili40
9 Most likely diagnosis? 1. Alcoholic hepatitis 2. Acute hepatitis B 3. Paracetamoloverdose 4. Myositis
10 Which parameter best stratify mortality risk? 1. ph 2. Lactate 3. Creatinine 4. Presence of encephalopathy 5. PT/INR 6. ALT
11 Management Initial priorities A, B, C, D NAC Antimicrobials Fluid resuscitation Early filtration Inotropic support Cerebral oedema management
12 Which mushroom is this? 1. Agaricusbisporus 2. Amanita phalloides 3. Psilocybesemilanceata 4. Agaricuscampestris
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16 Take home messages High ALT = acute insult (notalcohol) Low threshold for NAC
17 31 y o man presents to A&E with jaundice Most likely dx: 1. Acute hepatitis C 2. Decompensated NASH cirrhosis 3. Alcoholic hepatitis 4. Leptospirosis
18 31 y o female with alcoholic hepatitis Coagulopathy, sepsis, bili500, encephalopathy, melaena, O2 dependent, pancytopenia, hypotensive Management: 1. Palliation 2. ICU support Creatinine
19 31 y o female with alcoholic hepatitis Coagulopathy, sepsis, bili500, encephalopathy, melaena, O2 dependent, pancytopenia, hypotensive
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21 SOFA
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25 Take home message A trial of ICU therapy is often a reasonable approach for patients with acute on chronic liver failure
26 54 y o man with abnormal LFT Bloods ALP 163 (H) Alb 35 ALT 87 (H) Bili 20 HBsAg HBsAbIgG+ (IgM-) HBcAb + HBeAb + HBeAg Log 4 HBV viraemia Diagnosis? 1. Acute HBV 2. Chronic carrier 3. Active chronic hepatitis B 4. HBV cirrhosis
27 ACUTE HBV: Natural History Infection Incubation Symptoms Recovery 1-4 months 30% jaundice 90% recover 0.1% ALF
28 CHRONIC HBV: Natural History Immune suppression/ chemotherapy Clearance HBcAb+ HBsAg+ HBsAb- HBsAg- HBsAb+ HBeAg+ HBeAg+/- HBeAg- ABeAb- HBeAb+/- HBeAb+
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30 Diagnosis = HCC Management? 1. Chemotherapy 2. Liver transplantation 3. Resection 4. TAE 5. Ablation 6. SIRT
31 Take home messages 1. Always refer HBsAg+ patients 2. Test for viral hepatitis in context of long term immune suppression 3. Lots of treatment options for HCC including liver transplantation
32 SH; 17 Year Old Male Normally fit and well Non-smoker Admitted 25/8/16 under surgical team with 3/52 history of fevers and diarrhoea Acute worsening of diarrhoeawith associated abdominal pain in preceding 5 days O/E: Minimal tenderness noted RUQ and RLQ. No lymphadenopathy
33 Contrast enhanced CT scan What does the scan show? 1. Hepatitis 2. Cholecystitis 3. Thickened gastric mucosa 4. Portal vein thrombosis
34 CT Report Complete thrombosis of the portal vein with extension to the splenic vein, SMV and its branches
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37 GS 50 yr old man Heavy EtOH and history of depression. Fully abstient 4 years IV drug use in teens/early 20s. Liver Bx cirrhosis with moderate HCV activity Decision made not to treat with interferon October 2011 Admitted to hospital with peripheral oedema and ascites. Diuretics started March 2012 Increasing forgetfulness with reversal of sleep wake cycle Nov 2013 diuretic resistant ascites. April 2014 Listed liver for transplantation UKELD 56
38 GS Disease Progression Bilirubin Albumin PT
39 Any specific treatment?
40 Progress since EAP May 2014 Childs C cirrhosis decompensated with encephalopathy, jaundice and diuretic resistant ascites entered into early access programme 12 weeks oral therapy with sofosbuvir, ledipasvir and ribavirin Achieved sustained virological response (SVR 12) 19 th December 2014
41 GS Disease Delisted Nov 2014 Progression Coffee beard Beard shaved HCV Therapy SVR Sep-13 Jan-14 Dec-14 Apr-15 Bilirubin PT Albumin
42 Take home message New, highly effective treatments for HCV
43
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