MANAGEMENT OF LIVER CIRRHOSIS: PRACTICE ESSENTIALS AND PATIENT SELF-MANAGEMENT Sherona Bau, ACNP The Pfleger Liver Institute 200 UCLA Medical Plaza, Suite 214 Los Angeles, CA 90095 September 30, 2017
I have no disclosure. DISCLOSURE
OBJECTIVES What is liver cirrhosis Causes of liver cirrhosis Management of liver cirrhosis Patient Self-Management of liver cirrhosis
LIVER CIRRHOSIS A late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture and the formation of regenerative nodules. It is generally considered to be irreversible in its advanced stages The ideal treatment for decompensated liver cirrhosis may be liver transplantation. 4
LIVER DISEASES THAT LEAD TO LIVER CIRRHOSIS Hepatitis B Hepatitis C Autoimmune hepatitis Primary biliary cholangitis Primary sclerosing cholangitis Alcoholic liver disease Nonalcoholic steatohepatitis Hemochromatosis 5
PHYSICAL EXAMINATION Spider angiomata Palmar erythema Scleral icterus or jaundice BLE edema Ascites Anorexia 6
SPIDER ANGIOMATA 7
PALMAR ERYTHEMA 8
SCLERAL ICTERUS 9
EDEMA 10
ASCITES 11
TESTS FOR LIVER CIRRHOSIS ASSESSMENT Liver Biopsy Serum Biomarkers Elastography Routine Imaging Physical Examination
Histologic Staging Hepatitis C Normal Stage 1 2 Cirrhotic 3 4
LAB FINDINGS Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are usually moderately elevated. Normal AST and ALT do not preclude cirrhosis Low platelet counts < 150,000 Low albumin < 3.5 Bilirubin may be normal or elevated in cirrhosis progresses
SEROLOGIC TESTS 15
IMAGING OR EGD FINDINGS Ultrasound of abdomen can show Nodular liver Portal hypertension Splenomegaly Ascites Upper endoscopy may show esophageal varices MRElastography
PREDICTION OF PROGNOSIS Child-Pugh Classification MELD score (Model for end-stage liver disease)
CHILD-PUGH CLASSIFICATION OF CIRRHOSIS Parameter 1 2 3 Point 1 point 2 points 3 points Prothrombin 1-3 4-6 >6 Albumin >3.5 2.8-3.4 <2.8 Ascites none mild Moderatesevere Encephalopathy none Grade 1-2 Grade 3 or 4 Grade A: 5-6 points Grade B: 7-9 points Grade C: 10-15 points 18
MELD-NA SCORE
MANAGEMENT OF CIRRHOSIS Treatment goals for patients with cirrhosis: Slow the progression of liver damage Manage symptoms and reduce the risk for complications Treatment by a multi-disciplinary team is the ideal approach. 20
MANAGEMENT OF LIVER CIRRHOSIS Hepatocellular Carcinoma screening (US of abdomen + AFP) every 6 months EGD to screen esophageal varices Low sodium diet No raw fish or raw shellfish to prevent Vibrio vulnificus infection Avoid constipation Alcohol abstinence Small snacks between meals to maintain nutrient
DECOMPENSATED LIVER CIRRHOSIS Ascites Portal Hypertension Esophageal varices bleeding Encephalopathy Jaundice Muscle wasting Thrombocytopenia 22
ASCITES Diuretics Sodium monitoring Low sodium diet, < 2 gram per day Paracentesis as needed 23
ASCITES Diuretics If kidney function and electrolytes allow, single morning doses of oral spironolactone 100mg and furosemide 40mg. Spironolactone can increase potassium versus furosemide can lower potassium. The doses of both drugs an increased at the same time every 5-7 days. 24
ASCITES Amiloride 10-40mg per day can be substituted for spironolactone in patients with tender gynecomastia. Hydrochlorothiazide can cause rapidly development of hyponatremia when using with spironolactone and furosemide, it should be used extreme caution. 25
ASCITES Paracentesis Paracentesis can be performed as needed if a patient developed refractory ascites (diuretics-resistant tense ascites). Transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites 26
PORTAL HYPERTENSION Portal hypertension is resistance to portal blood flow and is aggravated by increased portal collateral blood flow. The resistance most often occurs within the liver (as is the case in cirrhosis), but it can also be prehepatic (eg, portal vein thrombosis) or posthepatic (eg, Budd-Chiari syndrome). 27
MANIFESTATIONS OF PORTAL HYPERTENSION Variceal hemorrhage Portal hypertensive gastropathy Ascites Hepatorenal syndrome Hepatic hydrothorax Hepatopulmonary syndrome Pulmonary hypertension 28
MANAGEMENT OF PORTAL HYPERTENSION Transjugular intrahepatic portosystemic shunt (TIPS) Purpose of a TIPS is to Decompress the portal venous system Prevent rebleeding from varices Stop or reduce the formation of ascites 29
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT
COMPLICATIONS OF TIPS 31
ESOPHAGEAL VARICES As a result of portal hypertension Screening for esophageal varices through upper endoscopy 32
ESOPHAGEAL VARICES
MANAGEMENT OF ESOPHAGEAL VARICES Esophageal varices non-bleeding Primary prophylaxis beta blockers Esophageal varices bleeding Esophagogastroduodenoscopy (EGD) with banding TIPs with rebleeding 34
ENCEPHALOPATHY Hepatic Encephalopathy (HE) HE is a brain dysfunction caused by liver insufficiency and/or Portal Systemic Shunting Wide spectrum of neurological or psychiatric abnormalities ranging from subclinical alterations to coma Clinically overt HE will occur in 30%-40% of those with cirrhosis and in most patients repeatedly Subjects with recurrent overt HE have a 40% cumulative risk of another recurrence within 6 months, despite standard treatment 35
GRADE OF ENCEPHALOPATHY Grade Definition I Changes in behavior with minimal change in level of consciousness II Gross disorientation, drowsiness, possibly asterixis, inappropriate behavior III Marked confusion, incoherent speech, sleeping most of the time but arousable to vocal stimuli IV Comatose, unresponsive to pain, decorticate or decerebrate posturing
FAMILY/PATIENT EDUCATION FOR ENCEPHALOPATHY Being confused Memory problems Mood changes Trouble speaking, drawing, and writing clearly Problems with sleep Some people have trouble falling asleep. Others sleep too much. Moving more slowly than normal Flapping hands
ASTERIXIS
PRECIPITATING CAUSES Dehydration Urinary tract infection Large volume paracentesis Constipation Large amount of red meat consumption Sleeping medication
MANAGEMENT OF ENCEPHALOPATHY Lactulose 30cc bid Goal 2 to 3 bowel movements per day Rifaximin 550mg po bid Avoid benzodiazepines Avoid pain medication 40
PATIENT SELF-MANAGEMENT FOR LIVER CIRRHOSIS Avoid NSAIDs Ok to take Tylenol no more than 2g/day Alcohol Constipation Raw shellfish Herbal supplement
PATIENT SELF-MANAGEMENT FOR LIVER CIRRHOSIS Daily weight Strict low sodium diet less than 1500mg per day. Low sodium should be < 140mg / serving Small snack between meals
FOOD HIGH IN SODIUM
FOOD HIGH IN SODIUM
FOOD HIGH IN SODIUM
FOOD HIGH IN SODIUM
FOOD HIGH IN SODIUM
FOOD HIGH IN SODIUM Deli meats hot dog - 700mg/serving Vegetable juices tomato juice - 700mg/serving Canned vegetable 1300mg/can Frozen meals 1800mg/serving Ketchup - 150mg/tablespoon, Soy sauce 1000mg/tablespoon Bread or tortillas 250 mg per serving Daily products cottage cheese, buttermilk or American cheese up to 400mg/ounce
CONCLUSION Liver cirrhosis is late stage of hepatic fibrosis potentially irreversible Manage symptoms and prevent decompensations Screening for hepatocellular carcinoma every 6 months Patient and family members play an important roles for prognosis of liver cirrhosis
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