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End of Life Care in Liver Disease

End of Life Care in Liver Disease. Dr Allister Grant Consultant Hepatologist Leicester Liver Unit East Leicestershire and Rutland CCG PLT 3rd Sept. Death rates for liver disease. Facts. Liver disease is the 5th largest cause of death in the U.K.

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End of Life Care in Liver Disease

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  1. End of Life Care in Liver Disease Dr Allister Grant Consultant Hepatologist Leicester Liver Unit East Leicestershire and Rutland CCG PLT 3rd Sept

  2. Death rates for liver disease

  3. Facts • Liver disease is the 5th largest cause of death in the U.K. • The average age of death from liver disease is 59 years, compared to 82-84 years for heart & lung disease • UK is one of few developed nations with an upward trend in mortality.

  4. Cirrhosis Expanded Portal Tracts (Blue)

  5. Prognosis- Child Pugh Score Score 1 2 3 Encephalopathy 0 I/II III/IV Ascites Absent Mild-moderate Severe Bilirubin (µmol/l) <34 34–51 >51 Albumin (g/l) >35 28–35 <28 INR <1.3 1.3–1.5 >1.5 Child-Pugh class A  6 B = 7–9 C 10

  6. Prognosis 1 Year Survival – Child Pugh A 80 - 100% – Child Pugh B 60 - 80% – Child Pugh C 35 - 45%

  7. Complications of End Stage Liver Disease • Decompensated Cirrhosis • Variceal bleeding • Ascites • Encephalopathy • Other • Sepsis (SBP) • Hepatorenal syndrome • Hepatocellular carcinoma

  8. Disease Progression 100% A B Liver function Cirrhosis Liver Failure Transplant Death C Years

  9. Disease Progression 50% Cirrhosis Liver function Liver Failure Transplant Death Months

  10. Portal Circulation

  11. Oesophageal varices

  12. Management of Bleeding Varices • Prevention • Resuscitation • Endoscopy - Band Ligation Sclerotherapy • Pharmacotherapy- Terlipressin • Balloon Tamponade • TIPS/Transplantation

  13. Oesophageal varices

  14. Bleeding Gastric Varices

  15. Variceal Bander

  16. Variceal Band Ligation

  17. Variceal Band Ligation

  18. Variceal Bleeding in Palliative Care • May be occult and present as encephalopathy -Gastric -Duodenal -Colonic • Resuscitate if appropriate • Correct coagulopathy • Give Terlipressin if known varices • As effective as balloon tamponade • As effective as endoscopic therapy • ?Give PPI / sucralfate / tranexamic acid • Colonic varices- rectal balloon tamponade

  19. Ascites

  20. Causes of Ascites 20% of patients with ascites have a non hepatic cause 5% of patients with hepatic ascites have a second cause Peritoneal disease- carcinomatosis, TB Heart failure Diabetic nephropathy Hypoalbuminaemia of other causes

  21. NaCl The Development of Ascites Peripheral arterial dilatation Reduced effective blood volume Hypoalbuminaemia Activation of renin-angiotensin-aldosterone system Sympathetic nervous system ADH Na retention & Water retention Ascites and Oedema Low urinary Na Dilutional hyponatraemia Plasma volume expansion Ascites Schrier et al Hepatol

  22. General Management Hepatic Ascites and Oedema • Salt restriction • Diuretics spironolactone frusemide • Water restriction if sodium < 125 mmol • Paracentesis diagnostic (SBP, tumour) therapeutic (Total vs partial + colloids) • Daily weight

  23. Sampling of Ascites • Coagulopathy is not a contraindication to diagnostic paracentesis (unless clinically evident fibrinolysis or DIC) • FFP/platelets are not required • In uncomplicated hepatic ascites request cell count and [Albumin] PMN>250 cells/mm3 indicates SBP transudate/exudate <25g/L/>25g/L serum/ascites albumin gradient >11g/L= Portal Hyp Runyon et al Ann Int Med 1992

  24. Spontaneous Bacterial Peritonitis Definition- “SBP is a bacterial infection of ascitic fluid which arises in the absence of any other source of sepsis within the peritoneum or adjacent tissues” PMN>250 cells/mm3 Mortality rate similar to that of a variceal bleed (20-40%)

  25. Secondary prevention of SBP • Patients who survive SBP have a 1y recurrence rate of 40-70% • Norfloxacin 400mg/day reduces recurrence from 68% to 20% • Locally we use Septrin 960mg od Mon-Fri • Median survival of these patients is 9mo • These patients should be considered for liver transplantation/ GSF

  26. Sepsis in Cirrhosis • Incidence- 1% of all admissions to hospital are due to sepsis 30-50% of cirrhotic patients admitted to hospital due to sepsis Once admitted 15-35% of cirrhotics develop infection (c.f. 5-7% general hospital population)

  27. General Management Encephalopathy Treat precipitants • Sepsis • GI bleed • Medications (over-diuresis) • Stop sedatives, hypnotics, opiates • Constipation Lactulose (NG/PR/PO) Metronidazole/ Rifaximin/ neomycin -deafness

  28. Acute Kidney Injury in CLD • Exclude urinary infection • Exclude obstructive uropathy • Trial of volume • Avoid nephrotoxins • NSAIDs • IV contrast • Avoid over-diuresis • Avoid hypotension • Hepatorenal Failure carries grave prognosis

  29. Hepatorenal Syndrome • Hepatorenal Syndrome is a severe complication of end stage liver disease associated with an 80%-95% mortality at 2 weeks. • The only interventions that have been shown to improve survival are liver transplantation, the vasopressin analogues and TIPS • Type 1 (Acute) • Type 2 (Chronic)

  30. HRS Survival Gines et al Lancet 2003

  31. Albumin NSAID Aminoglycosides Diuretics Sepsis Peripheral arterial dilatation Splanchnic vasoconstriction Terlipressin Renal vasoconstriction Reduced GFR NaCl HRS The Development of HRS Increases Reduced effective blood volume ↓ ↓ Activation of renin-angiotensin-aldosterone system Sympathetic nervous system ADH ↓ ↑Renal Perfusion X Na retention & Water retention Ascites and Oedema Low urinary Na Dilutional hyponatraemia Plasma volume expansion Ascites Schrier et al Hepatol

  32. Hepatocellular Carcinoma • All UK cirrhotic patients undergo 6 monthly HCC surveillance with USS and AFP • AFP >400 is diagnostic of HCC • Focal lesion – MRI/triple phase CT • Arterialised nodule, washout in venous phase

  33. Surveillance in Cirrhosis • Surveillance for Hepatoma 6 monthly AFP and USS

  34. Pruritis After exclusion of other causes of Itching consider • Biliary Obstruction • PBC in the absence of Jaundice • Cholestasis/Jaundice • Drugs

  35. Pruritis • Biliary Obstruction • Stones • Stricture • 1 or 2 Tumour • Nodes

  36. MRCP

  37. ERCP

  38. ERCP

  39. Drugs for Pruritis • Non-Specific Management • Lubricants/Topical agents • Reduce irritation • Prevent scratching • Systemic Anti-pruritics • Atarax • Fexofenidine etc • Liver Disease • Cholestyramine • Ursodeoxycholic acid • Rifampicin • Opioid antagonists, naloxone , naltrexone • Ondansetron

  40. Other Treatments • Ultraviolet light exposure • Plasmapheresis • Liver Transplantation

  41. Future • Liver disease is an important cause of mortality in the U.K. In 2000 it killed more men than Parkinson’s disease and more women than cancer of the cervix. • ~1% of population HCV positive • Mortality from Alcoholic liver disease doubled in 10 years • Incidence of liver cancer has doubled in 10 years • 4% of the population have abnormal liver function • 50% people with colorectal cancer develop liver metastases, 20% resectable

  42. The End “All right, let's not panic. I'll make the money by selling one of my livers. I can get by with one “ Doh!

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