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Chronic Liver Disease (CLD)

Chronic Liver Disease (CLD). Insidious onset Complication of viral infection, eg hepatitis Metabolic, eg alcohol Genetic, eg Haemachromatosis, Wilson’s, Porphyria Tumour Immunological, eg Primary Biliary Cirrhosis Drugs, eg Methotrexate, NSAIDs Obstructive, eg Budd Chiari.

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Chronic Liver Disease (CLD)

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  1. Chronic Liver Disease (CLD) • Insidious onset • Complication of viral infection, eg hepatitis • Metabolic, eg alcohol • Genetic, eg Haemachromatosis, Wilson’s, Porphyria • Tumour • Immunological, eg Primary Biliary Cirrhosis • Drugs, eg Methotrexate, NSAIDs • Obstructive, eg Budd Chiari

  2. Patient Presentation • “Flu” like symptoms (malaise) • Jaundice • Pruritis • Malnutrition • Ascites and peripheral oedema • Portal hypertension • Effect on other functions, eg respiratory, renal, cardiac, immune • May have pain • Encephalopathy

  3. Portal Hypertension • Caused by intra-hepatic resistance due to sinusoidal collapse • Causing “backflow” into circulatory system (collateral vessels) • Measured using invasive monitoring – Central Venous Pressure (CVP)

  4. Major Complication:Oesophageal Varices • Engorged vessels in lower oesophagus and around gastric cardia • Risk of bleeding – can be severe • Haemorrhage can occur at any time in CLD (30-50% of all deaths associated with CLD, especially Alcoholic Liver Disease)

  5. Treatment of Oesophageal Varices If haemorrhaging: • Replacement of blood volume (colloid, blood) • Urgent endoscopy • Sclerotherapy • Banding • Balloon tamponbade – if continued bleeding (Sengstaken tube) • Drug therapy • Acute, IV Vasopressin • Long-term, beta blockers, antacids

  6. Hepatic Encephalopathy • Disordered consciousness (confusion) • Occurs both in chronic liver failure and acute • Various theories on cause • Abnormal ammonia metabolism most likely (Ammonia is a by-product of protein metabolism, healthy liver converts ammonia to urea then excreted by kidneys) • Encephalopathy classified into four grades

  7. Treatment of Hepatic Encephalopathy • Maintain safe environment • Monitor level of consciousness • Regular laxative – Lactulose (20–30 mls tds.) • Phosphate enemas (We no longer restrict protein intake)

  8. Ascites • Ascites: Marked increase in the volume of fluid in the peritoneal cavity • Rarely painful, unless infected, • Respiratory complications, • Haemodynamic complications  CVP  MAP • Renal impairment • Reduced mobility and nutrition

  9. Treatment of Ascites • Low sodium diet • Fluid restriction (1500ml / 24 hours) • Diuretic therapy – Spironolactone • Abdominal Paracentesis – with IV Albumin replacement

  10. Stigmata of Chronic Liver Disease • Gynaecomastia • Palmar Erythema • Dupytrens Contracture • Caput Medusae • Fetor Hepaticus • Jaundice • Clubbing • Spider Naevi • Xanthomata • Hair loss • Asteriscis (tremor)

  11. Alcohol Withdraw • Can occur after a short but sustained alcohol binge • Early intervention will halt progression to delirium tremens (DTs) • Signs and symptoms • Nervousness • Restlessness • Tremor (flap) • Confusion • Nausea and vomiting • Patient may hallucinate • Risk of seizures

  12. Acute Liver Disease (ALD) • Onset of days or weeks • Complication of viral infection, eg hepatitis • Drugs, eg Paracetamol, NSAIDs • May lead to Fulminant hepatic failure • ? Need for transplant

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