End Stage Liver Disease

End Stage Liver Disease

Hepatic Failure

·        Conjugated jaundice

·        Fatigue, muscle wasting, brusiability

·        ¯Platelet count (reliable early indicator of cirrhosis) 

·        ¯Synthesis: notably of albumin

·        Fluid retention, ascites, spontaneous bacterial peritonitis

·        Coagulopathy: ¯synthesis of 2, 5, 7, 9, 10 

·        Hyperammonaemia ®metabolic encephalopathy

·        Gynaecomastia (steroid hormones not metabolised)

·        Hepatocellular carcinoma

·        Hepato-renal Syndrome: 

o   Renal failure in patients with liver failure ® ­urea and creatinine

o   Blood is hyperosmolar but urine sodium is low

o   Pathogenesis unknown: possibly vasoconstriction

·        Hepatic Encephalopathy:

o   Metabolic derangement of the brain: only mild morphologic changes (eg oedema)

o   Flapping tremour 

o   Grade 1 – altered mood, confusion, 2 – drowsy, disorientation, ataxia, 3 – marked confusion, sleepy, obey simply commands, 4 - coma

·        Which lead to liver failure or transplantation

Portal Hypertension

·        Diagnosed clinically: if cirrhosis, ascites and varices assume portal hypertension. Can confirm with Doppler ultrasound

·        Causes:

o   Post-hepatic: vascular outflow obstruction (Budd Chari Syndrome)

o   Intrahepatic: cirrhosis

o   Prehepatic: portal vein occlusions

·        Consequences: 

o   Ascites: ¯albumin synthesis, ­portal pressure, ­hepatic lymph formation and renal retention of sodium and water 

o   Portosystemic shunts: oesophageal varices, haemorrhoids and abdominal wall

o   Splenomegaly and portal congestive gastropathy

·        Treatment of varices:

o  Complicated by hypo-coagulopathy secondary to liver failure (do INR and APPT) 

o  Band oesophageal varices lower down: collapses them further up. Varices are asymptomatic until eroded by acid or increased pressure from vomiting

o  Emergency therapy for bleeding varices:

§  Octreotide infusion (somatostatin analogue but longer T½) ® reduce portal pressure

§  Balloon tamponade

§  Resuscitation 

§  Then emergency endoscopy with sclerotherapy (takes several iterations) or banding, or TIPS/surgery (portal/caval shunt)

o  Maintenance treatment: 

§  Sucralfate (an Al carbohydrate): 1 gm 1 hr ac QID - surface protective effect to stop ulcers over sclerosed varices 

§  Beta blocker: propranolol, nadolol ® ¯CO due to ¯HR

Nutrition

·        Malnutrition is common in chronic liver disease due to ¯absorption and ¯synthesis

·        Give ­fat and ¯CHO to combat hyperglycaemia resulting from insulin resistance

·        If encephalopathy, then low protein diet, antibiotics to decrease bacterial ammonia production and lactulose (¯transit time & metabolised by bacteria ® ­H+ which converts NH3 to less absorbable NH4)