Liver cirrhosis There s more of it out there than you think!

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1 Liver cirrhosis There s more of it out there than you think! Esther A Pears Lead Hepatology Specialist Practitioner Manchester Royal Infirmary Jessy Joseph Hepatology Specialist Practitioner Manchester Royal Infirmary

2 Aims Recognising advanced liver disease in asymptomatic individuals. What are the causes? Outlining the advance of Hepatitis C management

3 The Liver The liver is the second largest organ in the body. It weighs approximately 1.8kg in men & 1.3kg in women It holds approximately 13% (about one pint or 0.57 litres) of your total blood supply It is estimated to have over 500 functions.

4 Where is the liver? If you place your right hand over the area under the ribs on the right side of your body it will just about cover the area of your liver.

5 Some of the functions of the liver Fighting infections and illness Removing toxins (poisons), such as alcohol, from the body Controlling cholesterol levels Helping blood to clot (thicken) Releasing bile, a liquid that breaks down fats and aids digestion

6 Overview There are more than 100 different types of liver disease. Together they affect at least 2 million people in the UK.

7 Liver Diseases Alcohol related liver disease Autoimmune hepatitis Budd Chiari Benign tumours Cystic disease of the liver Cirrhosis of the liver Fatty liver & NASH Haemochromatosis Hepatitis ABCD Liver cancer Primary biliary cirrhosis Primary sclerosing cholangitis Wilson s disease

8 Liver disease doesn't usually cause any obvious signs or symptoms until it's fairly advanced and the liver is damaged

9 Normal & Cirrhotic Liver

10 Signs & Symptoms Fatigue Bleeding easily Bruising easily Itchy skin Yellow discoloration to skin/eyes (jaundice) Fluid accumulation in your abdomen (ascites) Loss of appetite Nausea Swelling in the legs Weight loss Confusion/drowsiness & slurred speech (hepatic encephalopathy) Spider like blood vessels on your skin

11 Complications of cirrhosis (1) Decreased liver function Jaundice Low albumin Low clotting factors oestrogen clearance

12 Complications of cirrhosis (2) Portal hypertension Oesophageal varices Rectal varices Caput medusa Ascites Renal failure

13 Complications of cirrhosis (3) Hepatoma

14 Hepatic encephalopathy Varies from mild cognitive impairment to coma Early signs Hepatic flap Change in personality Day-night reversal Reduced reaction times Impaired driving safety Increase sensitivity to opiates

15 Ascites Ascites is the most common complication of liver cirrhosis The onset of ascites marks a critical point in the progression of liver disease, indicating a 50% mortality rate within 2-5 years Ascites is typically well managed with a low sodium diet and diuretic therapy

16 Refractory Ascites In 10% of cirrhotic patients with ascites, maximal diuretic therapy is not effective In these patients with refractory tense ascites, repeated large volume paracentesis becomes the mainstay of chronic management

17 Non Laboratory Tests Liver Fibroscan Picture of fibroscan Ultrasound Liver biopsy

18 Laboratory Tests ALT an enzyme found mainly in the liver. Values may increase with with all types of liver injury including cirrhosis AST an enzyme found in the liver and other organs, elevated in people with liver injury including cirrhosis ALP an enzyme found along the bile ducts usually normal or mildly elevated in cirrhosis Total bilirubin a substance produced exclusively in the liver increased in cirrhosis Albumin a protein made by the liver often decreased in cirrhosis Platelets are often decreased with cirrhosis Prothrombin time (PT/INR) most clotting factors are produced by the liver results may be prolonged in cirrhosis

19 There are many causes of liver disease but there are three main threats to your liver s health which you can protect yourself from:

20 Alcohol related liver disease Alcohol related liver disease where the liver is damaged after years of alcohol misuse, this can lead to cirrhosis (scarring of the liver) If you regularly drink more than a pint or two of beer, or a couple of glasses of wine each day, you re putting the liver under incredible strain.

21 Know your units Men and women should drink no more than 14 units in a week Don t save up several days allowance and drink it all at once Have a couple of alcohol free days in the week

22 How alcohol hurts your liver A quarter of us drink at levels that could put our health at risk Regularly drinking more than the recommended amount over a long period can damage your liver. This can lead to alcohol related liver disease (ALD) and liver cancer

23 How to look after your liver Take two days off. Give your liver two days in a row without alcohol every week to reduce the impact that alcohol can have on your liver and break the habit of drinking every day.

24 Non Alcoholic Fatty Liver NAFLD Many of us are overweight and don t do enough exercise Fatty deposits can build up in your liver which can cause inflammation and scarring. This is more likely to happen if you are overweight, diabetic or regularly drink too much alcohol.

25 How does NAFLD affect my liver? The first stage is fatty liver, or steatosis. This is where fat accumulates in the liver cells without any inflammation or scarring. For many people, the condition will not advance and a serious liver condition will not develop

26 NAFLD can progress on to NASH. Non-alcoholic steatohepatitis (NASH) is a more significant condition, as it may cause scarring to the liver, and can progress to cirrhosis. Cirrhosis causes irreversible damage to the liver and is the most severe stage of NAFLD. NAFLD is recognised as one of the most common forms of liver disease worldwide and one that can progress to advanced liver damage.

27 Four stages of NAFLD 1. Non-alcoholic fatty liver or steatosis 2. Non-alcoholic steatohepatitis (NASH) 3. NASH with fibrosis 4. Cirrhosis

28 How to look after your liver Keep to a healthy weight If you re overweight, get help to lose weight safely avoid crash diets and rapid weight loss Eating plenty of fruit and vegetables is important Drink plenty of water

29 Hepatitis Inflammation (swelling) of the liver caused by exposure to harmful substances such as alcohol or viruses

30 Viral Hepatitis Viral hepatitis affects over 700,000 people in the UK There are several viruses that cause hepatitis. The common ones are hepatitis A, B and C. Most people recover from hepatitis A with no lasting liver damage, but hepatitis B and C can cause long term liver disease and even liver cancer.

31 Hepatitis A Hepatitis A is passed out in the bowel motions of an infected person, and is passed from person to person by eating food or drinking water contaminated with the virus due to poor hygiene standards. There are vaccines available to protect against hepatitis A. Vaccination is recommended if you are travelling abroad outside Europe and the US

32 Hepatitis B Hepatitis B virus is found in blood and body fluids and causes liver damage. It is times more infectious than HIV. Some people may only have a mild illness and feel they are not ill enough to see a doctor. A few people develop a serious illness and need to be looked after in hospital. More severe symptoms may include: diarrhoea, pale bowel motions, dark urine, jaundice

33 Treatment of Hepatitis B People with the acute phase of hepatitis B, do not require treatment. For the majority of people, the symptoms resolve and the person can clear the infection, usually within six months, meaning they are no longer infectious Their blood will always show the hepatitis B antibodies but they should never be infected again (they become immune ).

34 Chronic Hepatitis B Long term infection is chronic hepatitis B which often requires treatment to stop or reduce the activity of the virus from damaging the liver, by limiting the replication of the virus. Not everyone will require treatment straight away. If you have low levels of the virus in your blood (a low viral load) and there is little sign of liver damage, it is likely that regular monitoring will be recommended and treatment started only if there are signs of disease

35 Hepatitis C Hepatitis C, is a virus that is carried in the blood which infects and damages the liver. The hepatitis C virus infects the cells in your liver, causing inflammation (swelling and tenderness) and fibrosis. In people with chronic (longterm) hepatitis C infection, inflammation and fibrosis continues to spread and over time lead to cirrhosis Cirrhosis can take many years to develop and can do so without any noticeable symptoms until the damage to the liver is very serious. The build-up of scar tissue can interfere with the flow of blood to your liver and stop it from functioning properly. Cirrhosis can lead to liver failure.

36 Time course of liver inflammation Acute hepatitis Recovery 25% 75% Fulminant hepatitis <0.1% Chronic hepatitis Death Transplantation Increasing fibrosis Liver failure Cirrhosis

37 New Direct Acting Anti Viral Medication for the treatment of Hepatitis C Genotype 1 Elbasvir/Grazoprevir (Zepatier ) ± Ribavirin Ledipasvir/Sofosbuvir (Harvoni ) ± Ribavirin Genotype 2 Pegylated Interferon & Ribavirin Sofosbuvir & Ribavirin Genotype 3 Sofosbuvir/Velpatasvir (Epclusa ) ± Ribavirin Sofosbuvir/Pegylated Interferon & Ribavirin Genotype 4 Elbasvir/Grazoprevir (Zepatier ) ± Ribavirin Ombitasvir/paritaprevir/ritonavir (Viekirax ) with or without Dasabuvir (Exviera ) Genotype 5 & 6 Sofosbuvir/Velpatasvir (Epclusa ) ± Ribavirin Sofosbuvir / Pegylated Interferon / Ribavirin

38 Significant health problems In the UK, liver disease is on the increase. Three of the main causes of liver disease are: Obesity Undiagnosed Hepatitis infection Alcohol Misuse

39 Preventable These causes of liver disease are all preventable so it's important to make sure: You're a healthy weight for your height; check your body mass index (BMI) Avoid drinking excessive amounts of alcohol Take the appropriate measures to prevent getting hepatitis, such as getting vaccinated against hepatitis A and B Know if you are at risk of getting or having hepatitis C

40 CMFT Specialist Medicine Rapid Access Ascitic Drain Service Historically most of our patients came through the acute medical wards to have their ascites drained Poor patient experience Sometimes waiting days in discomfort for a bed to become available Some ending up in A/E as their symptoms became so severe

41 Training & Competency

42 Specialist Medicine Day Unit If patients require a drain this can be done often the next day or certainly within a few days on the Specialist Medicine Day Unit (SMDU). Patients attend SMDU early in the morning for drain insertion and following removal of the drain are discharged late afternoon/early evening of the same day.

43 Mike Excessive drinking has caused Mike's ascites. Water tablets are not effective; TIPSS procedure and liver transplant are no longer an option. He hasn't drunk any alcohol for years now. He is end of life and tethered to weekly hospital visits for ascitic drains Mike would travel to hospital on the bus sometimes having to get off before his stop because of the urgent need to go to the toilet caused by the huge volume of ascitic fluid pressing on his bladder. Mike would often arrive at hospital only to be told that the bed wasn't ready. He would wait in a day room for a few hours and even when the bed did become available he would then have to wait for someone to do the drain.. It was not unusual for Mike to be in a hospital bed for two to three days for an ascitic drain

44 Mike Mike lived for many months with the uncertainty of where and when he would have his drain. Pressure on hospital beds was such that he would often go for longer periods in between drains. As his belly grew and his discomfort worsened so did his worry and anxiety. Mike is now in a situation where he knows exactly where and when he will have his ascitic drain and who will do the procedure. He attends SMDU at 0815 and usually leaves the unit mid afternoon. He doesn't travel on the bus anymore, hospital transport has been arranged. Last month Mike travelled home to Portugal to spend a week with his family!

45 Mary Mary grew up in a pub she was no stranger to alcohol from an early age Mary s husband died two years ago and her life fell apart.she was already drinking alcohol to excess now she drinks even more Mary was admitted to the acute medical ward with alcohol related liver disease and ascites She spent 4 months on the ward with weekly ascitic drains Mary was miserable. Mary was transferred to a rehabilitation ward and eventually had a complex discharge involving the mdt She had her first drain on SMDU November 2016 and her last beginning of January 2017 Mary hasn t been drained sincece! What happened in between?...mary stopped drinking

46 James. James had hepatitis C, now cured. He has liver cirrhosis and sadly developed hepatocellular carcinoma. He is at the end of his life and dealing with the awful consequences of his liver disease. James hates coming into hospital He is well supported by the Macmillan Team in the community and now we are able to offer our own support in providing James with a day case paracentesis service James died today...

47 Thank you