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Cirrhosis 18 November 2009

Cirrhosis 18 November 2009. Thomas C Sodeman MD Associate Professor of Medicine Chief, Division of Gastroenterology. Cirrhosis. Definition Diagnosis Pathogenesis Treatment Outlook. Cirrhosis. Definition

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Cirrhosis 18 November 2009

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  1. Cirrhosis18 November 2009 Thomas C Sodeman MD Associate Professor of Medicine Chief, Division of Gastroenterology

  2. Cirrhosis • Definition • Diagnosis • Pathogenesis • Treatment • Outlook

  3. Cirrhosis • Definition • Distortion of hepatic architecture by fibrosis and attempted regeneration that leads to loss of function, portal hypertension, and potential hepatocellular malignancy.

  4. Cirrhosis http://www.hivandhepatitis.com/2006icr/ddw/images/cirrhosis-liver.jpg

  5. Cirrhosis http://www.pathology.vcu.edu/education/gi/images/3.3h-b.jpg

  6. Cirrhosis • Causes • Alcohol • NASH • HBC, HCV, HDV • Iron, copper • Autoimmune • PSC, PBC, SSC • Vascular • a1-AT • Drugs • ?

  7. Cirrhosis • Diagnosis • Clinical • Laboratory • Radiologic

  8. Cirrhosis • Diagnosis • Clinical • Silent • Ascites • Encephalopathy • Sleep-wake reversals • Variceal bleeding • Muscle wasting • Gynecomastia • Spiders

  9. Cirrhosis

  10. Cirrhosis http://www.hepatitis.cl/images/varices.jpg

  11. Cirrhosis http://www.medscape.com/content/2000/00/40/55/405535/art-mgi7381.lang.Fig2.jpg

  12. Cirrhosis http://content.answers.com/main/content/wp/en/thumb/9/91/200px-IGV1.jpg

  13. Cirrhosis • Diagnosis • Laboratory • Synthetic defect • Albumen, INR • Thrombocytopenia • Ammonia • Bilirubin • AST / ALT • aFP

  14. Cirrhosis • Diagnosis • Radiologic • Can rule in but not rule out • Sensitivity and specificity of 80% • Splenomegaly, varices, ascites

  15. Cirrhosis

  16. Cirrhosis

  17. Cirrhosis

  18. Cirrhosis

  19. Cirrhosis

  20. Cirrhosis

  21. Cirrhosis

  22. Cirrhosis • Diagnosis • Biopsy • 1% risk of complications • Often understages • Misdiagnosed in 10-30% • Optimal biopsy 40 mm • Average 16 mm

  23. Cirrhosis • Diagnosis • Noninvasive • Fibroscan • Fibrosure • Actitest • AST/platelet ratio ( AST / ULN)/PLT (109/L)×100.

  24. Cirrhosis • Pathogenesis

  25. Cirrhosis

  26. Cirrhosis • Treatment • Treat underlying disease • Treat manifestations • Screen for problems • Varices • HCC • Transplantation

  27. Cirrhosis • Treatment • Treat underlying disease • HBV/HCV – slow progression • HHC – slow progression • AIH – slow progression • EtOH – slow progression

  28. Cirrhosis • Treatment • Treat manifestations • Ascites • Encephalopathy • Varices

  29. Cirrhosis

  30. Cirrhosis • Treatment • Treat manifestations • Ascites • Tap • SAAG >1.1 • Culture • Cytology • Albumen • Lasix / aldactone • Salt restriction 2g/day • Tap / TIPS

  31. Cirrhosis • Treatment • Treat manifestations • Ascites • SAAG • >1.1 Cirrhosis, CHF, Mets, FHF, Budd-Chiari • <1.1 Peritoneal Ca, TB, bile leak, nephrotic syndrome

  32. Cirrhosis • Treatment • Treat manifestations • Ascites • Tap • 1100 LVP • INR 8.7 • Plt 19 • No major complications Hepatology 2004: 40:484-488

  33. Cirrhosis • Treatment • Treat manifestations • Ascites • “Failure” • High salt diet • IV fluids • NSAIDS Hepatology 2004: 40:484-488

  34. Cirrhosis • Treatment • Treat manifestations • Ascites • SBP • >250 PMN • Cefotaxime • Quinolones Hepatology 2004: 40:484-488

  35. Cirrhosis • Treatment • Treat manifestations • Hepatorenal syndrome • GFR>1.5 or CrCl <40 • No shock, infection, etc • Urine protein <500 mg/day Hepatology 2004: 40:484-488

  36. Cirrhosis • Treatment • Treat manifestations • Hepatorenal syndrome • Current treatment • Preventive • Transplant • Midodrine / octreotide Hepatology 2004: 40:484-488

  37. Cirrhosis • Treatment • Treat manifestations • Varices • Predict with thrombocytopenia • Grading I-IV • Bleeding risk with III IV • Screen • Repeat in 1-2 years if grade I or II • Repeat in 6 months if III IV

  38. Cirrhosis • Treatment • Treat manifestations • Varices • Bleeding carries up to 50% mortality • Transfusion to Hb 8 • Octreotide • Intubation • Endoscopy • b blockers • Antibiotics for SBP

  39. Cirrhosis • Outlook • Bad • Mortality • Compensated • Decompensated • Variceal bleed 20% • Ascites 50% 2 year

  40. Cirrhosis • Outlook • Hepatocellular carcinoma • Risk 1-5%/year • Increased with: • Male • Iron • HBV • a1AT

  41. Cirrhosis • Outlook • Transplantation • HCV/alcohol • NASH • HCC • PBC/PSC

  42. Cirrhosis • Outlook • Transplantation • MELD score • MELD Score = 10 {0.957 Ln(Scr) + 0.378 Ln(Tbil) + 1.12 Ln(INR) + 0.643}

  43. Cirrhosis • Key points • Diagnosis • Anything fixable? • Management of manifestations • Screening for problems • Transplantation

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