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LIVER CIRRHOSIS IN PSC: DIAGNOSIS AND MANAGEMENT

LIVER CIRRHOSIS IN PSC: DIAGNOSIS AND MANAGEMENT. Douglas A Simonetto, M.D. Assistant Professor of Medicine Mayo Clinic, Rochester, MN. THE NORMAL LIVER OFFERS ALMOST NO RESISTANCE TO FLOW. Normal Liver. Hepatic vein. Liver. Portal vein.

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LIVER CIRRHOSIS IN PSC: DIAGNOSIS AND MANAGEMENT

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  1. LIVER CIRRHOSIS IN PSC:DIAGNOSIS AND MANAGEMENT Douglas A Simonetto, M.D. Assistant Professor of Medicine Mayo Clinic, Rochester, MN

  2. THE NORMAL LIVER OFFERS ALMOST NO RESISTANCE TO FLOW Normal Liver Hepatic vein Liver Portal vein

  3. ARCHITECTURAL LIVER DISRUPTION IS THE MAIN MECHANISM THAT LEADS TO AN INCREASED INTRAHEPATIC RESISTANCE Cirrhotic Liver Varices Distorted architecture Portal Hypertension Enlarged spleen

  4. NATURALHISTORY Chronic Liver Disease ? years Compensated Cirrhosis Portal Hypertension ~ 10 years Decompensated Cirrhosis Complications Of Liver Disease ~ 2-5 years Liver Transplantation

  5. DIAGNOSIS OF CIRRHOSIS Liver Biopsy

  6. DIAGNOSIS OF CIRRHOSIS Transient Elastography (FibroScan)

  7. DIAGNOSIS OF CIRRHOSIS Magnetic Resonance Elastography (MRE)

  8. COMPLICATIONS OF CIRRHOSIS • Varicose veins in the esophagus (esophageal varices) • Fluid in the abdomen = Ascites • Confusion = Encephalopathy

  9. VARICOSE VEINS IN THE ESOPHAGUS

  10. VARICOSE VEINS IN THE ESOPHAGUS No varices Small varices Large varices

  11. PREVENTION OF VARICEAL BLEEDING Nonselective Beta-Blockers • Nadolol • Propranolol • Carvedilol Band Ligation

  12. PREVENTION OF VARICEAL BLEEDING Diagnosis of Cirrhosis

  13. PREVENTION OF VARICEAL BLEEDING Diagnosis of Cirrhosis Endoscopy

  14. PREVENTION OF VARICEAL BLEEDING Diagnosis of Cirrhosis Endoscopy No Varices Follow-up EGD in 2-3 years

  15. PREVENTION OF VARICEAL BLEEDING Small Varices Follow-up EGD in 1-2 years Diagnosis of Cirrhosis Endoscopy No Varices Follow-up EGD in 2-3 years

  16. PREVENTION OF VARICEAL BLEEDING Large Varices Small Varices Follow-up EGD in 1-2 years Beta-blocker therapy Diagnosis of Cirrhosis Endoscopy No Varices Follow-up EGD in 2-3 years

  17. PREVENTION OF VARICEAL BLEEDING Large Varices Small Varices Follow-up EGD in 1-2 years Beta-blocker therapy • Stepwise increase until maximally tolerated dose • Continue beta-blocker indefinitely • No need for repeat/serial EGD Diagnosis of Cirrhosis Endoscopy No Varices Follow-up EGD in 2-3 years No Contraindications

  18. PREVENTION OF VARICEAL BLEEDING Small Varices Follow-up EGD in 1-2 years Endoscopic Variceal Band Ligation Diagnosis of Cirrhosis Endoscopy No Varices Large Varices Follow-up EGD in 2-3 years Beta-blocker therapy No Contraindications • Stepwise increase until maximally tolerated dose • Continue beta-blocker indefinitely • No need for repeat/serial EGD Contraindications or Beta-blocker intolerance

  19. ASCITES (FLUID IN THE ABDOMEN) • Most common complication of cirrhosis • Symptoms: • Distention/bloating • Decreased appetite • Shortness of breath

  20. ASCITES (FLUID IN THE ABDOMEN) • Step 1: Sodium Restriction • 2,000 mg of sodium per day • Step 2: Combination Diuretics • Furosemide and Spironolactone

  21. ASCITES (FLUID IN THE ABDOMEN) Step 3:Large Volume Paracentesis • Safe to repeat as needed • Bleeding risk <0.3% • Intravenous albumin sometimes needed Step 4:TIPS

  22. Transjugular Intrahepatic Portosystemic Shunt (TIPS)

  23. CONFUSION (ENCEPHALOPATHY) • Brain dysfunction caused by toxins (including ammonia) • Wide spectrum of symptoms • Mood changes, sleep issues to disorientation, drowsiness and slurred speech

  24. Encephalopathy CONFUSION (ENCEPHALOPATHY) Toxins Step 3:Large Volume Paracentesis • Safe to repeat as needed • Bleeding risk <0.3% • Intravenous albumin sometimes needed Step 4:TIPS Toxins Shunting Failure to filter/metabolizetoxins Waste products

  25. CONFUSION (ENCEPHALOPATHY) • Treatment: • Lactulose • Laxative – 3-5 bowel movements • Rifaximin • Antibiotic – Taken twice a day

  26. SUMMARY • Diagnosis • FibroScan • MRE • Liver Biopsy • Labs/Imaging • Ascites (fluid in the abdomen) • Sodium restriction • Diuretics • Paracentesis • TIPS • Varicose veins in the esophagus • Endoscopy • Nadolol, propranolol, carvedilol • Band ligation • Encephalopathy (confusion) • Lactulose • Rifaximin

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