Chronic liver disease

Introduction:

·         Primary care physicians play a key role in early identification of risk factors, in the management of patients for improving quality and length of life, and for preventing complications.

·         Specialists, by contrast, should guide specific treatments, especially in the case of complications and for selecting patient candidates for liver transplantation.

Etiology:

·         Hepatitis B

·         Hepatitis C

·          Non Alcoholic Steato Hepatitis(NASH)

·         Alcohol abuse

·         Others e.g. Primary biliary cirrhosis, α₁-antitrypsin deficiency, Hemochromatosis, Wilson disease, cryptogenic.

Clinical Features:

·         Often asymptomatic

·         May present with stigmatas of CLD such as vascular spiders, palmar erythema, spider angiomata, palmar erythema, Gynaecomastia, dilated abdominal veins, loss of hair, testicular atrophy.

·          jaundice, ascites, splenomegaly and asterixis  indicate signs of decompensation

·         Patients may be diagnosed incidentally through laboratory findings

Investigations:

• ·         CBC
• ·         Liver function tests ( S. Bilirubin , SGOT, SGPT, ALP, S.albumin, A: G Ratio, Prothrombin Time)
• ·         S. electrolytes,
• ·         S. creatinine
• ·         USG of whole abdomen—coarse liver, splenomegaly, ascites
• ·         Viral Marker ( HBS Ag, Anti HCV)

Management:

A. General

Nutrition, Fluid and Electrolyte:

• Diet according to patient’s status eg.  Malnourished (high protein and carbohydrate), hepatic encephalopathy/precoma (Protein restriction) Ascites (salt restriction).
•  Lactulose in constipation (20 – 30 ml/day)
• Stop OCP, Sedatives, NSAID and Paracetamol.

 B. Management according to presentation:

Ascites

• ·         No added salt,
• ·         Paracentesis  for diagnosis and therapy:
•           Send sample for biochemistry/cytology and C/S if possible.
• ·         Spironolactone (100 mg - 400 mg daily) and/or furosemide (40 mg - 160 mg daily),
•           Measure weight  daily, target weight loss at ~500g/day.
•           The dose of diuretics - increased every 3–4 days to achieve target weight loss.
• ·         For spontaneous bacterial peritonitis (SBP), based on abdominal pain, fever, and ascitic fluid report.
•            Start IV Cefotaxim 1g tds/ ciprofloxacin 200mg IV BD for 7 - 10 days.
•           Antibiotic  prophylaxis  included ciprofloxacin ,750 mg orally once weekly
• ·         If there is massive ascites –   Refer to secondary level/ Tertiary level

Hepatic Encephalopathy  

Grade I: Changes in behaviour with minimal change in level of consciousness

Grade II: Disorientation, drowsiness, asterixis, inappropriate behaviour

Grade III: Marked confusion, incoherent speech, sleeping but rousable

Grade IV: Comatose, unresponsive, decorticate or decerebrate posturing

• ·         Avoid sedatives/ diuretics
• ·         Maintenance of Nutrition and fluid  balance
• ·         Lactulose 20mL tds (titrate dose to achieve at least 2 loose stools/day),  if necessary enema until 2–4 bowel movements/day .
• ·         Amoxicillin (500mg TDS)/ Metronidazole (400mg TDS)/Rifaximin (400 mg TDS) for gut sterilization.
•      Grade 3 or 4 encephalopathy-Refer           

Hematemesis and Melaena

·         I/V Fluid (N/S, Hartman sol.), Immediate blood transfusion and refer.                                                                                                                                                                                                                  

 Coagulopathy  Characterized by  prolonged prothrombin time

·           Vitamin K - 10mg I/V for 3 days.

Severe coagulopathy, Vit K can be given IV 10mg slowly and Refer

Hepatorenal syndrome – Characterized by oliguria in cirrhotic patient without proteinuria and abnormal sediment in urine.

·         Refer.

·         Before referral--   Stop  diuretics & NSAIDs and Catheterise bladder

Indication for Referral:

1.  Decision for antiviral therapy   2.  Variceal   haemorrhage    3.  Massive ascites                4.  Diagnostic and  therapeutic   Endoscopy. 5.  Encephalopathy Grade III & IV                    6.  Hepatorenal syndrome  7. Multi-organ failure   8.  Hepatocellular carcinoma.                                                                                                                     

Acute hepatitis

Introduction:

·         Acute hepatitis should be reserved for patients who present with a syndrome of anorexia, jaundice and elevated ALT.

·   It is most often caused by viruses that are hepatotropic  ( hepatitis A, B, C, D, and E). Cytomegalovirus (CMV), herpes simplex, coxsackievirus, and adenovirus may also occasionally affect the liver.

Clinical features:

·         Anorexia, Nausea, Vomiting,

·         Jaundice

·         Dark urine,

·         Low grade fever,

·         Tender hepatomegaly

Investigation:

• ·         S. Bilirubin,  ALT
• ·         USG of HBS
• ·         CBC
• ·         Viral Marker-- Anti-HAV ,  Anti HEV, HBsAg
• ·         Prothombin Time

 

N. B. ALP should done in  clinical suspicion of  Obstructive jaundice ( Jaundice, Pale stool and generalized itching)

Management :

·         Supportive:

--Give i.v. fluids- if unable to take per oral

--Anti emetic- if needed

-- Constipation- Lactulose : 20-30 ml per day

--Correct prothombin time-By Vitamin K 10 mg I/V for 3 days

·         Specific :

-- No antiviral for HAV, HEV

--Antiviral for HBV  is be decided by specialist.

·         Stop all OCP, NSAID, Sedatives and Paracetamol. Vitamin supplementation is of no use.

N.B: Look for Altered consciousness, Flaps, Sleep disturbance, Bradycardia and High BP (signs of fulminant hepatic failure) and consider immediate referral.

Indication of hospitalization:

·         Deep jaundice

·         Intractable vomiting

·         High fever

·         Features of encephalopathy (grade I & II)

·         Pregnancy

   Grade I: Changes in behaviour with minimal change in level of consciousness

   Grade II: Disorientation, drowsiness, asterixis, inappropriate behaviour

   Grade III: Marked confusion, incoherent speech, sleeping but rousable

   Grade IV: Comatose, unresponsive, decorticate or decerebrate posturing

Referral to a specialist is recommended under the following circumstances:

·         Gradual deterioration of general condition

·         Progessively increasing prothombin time

·         Signs of encephalopathy (grade III & IV)

·         Pregnancy with HEV infection

HBV for further evaluation and management.

Helminthiasis

Introduction:

Helminthiasis is infestation with one or more intestinal parasitic worms (nematodes and cestodes), which   are commonly associated with poor personal and environmental hygiene and transmitted through contaminated soil.  Infection contributes to anemia, vitamin A deficiency, malnutrition and impaired growth, delayed development, and intestinal blockages.

Clinical features  :

·         Asymptomatic

·          Abdominal pain 

·          Diarrhoea

·         Vomiting 

·         Itchy anus

·         Fatigue  

·         Fever  

·         Cough 

·         Malabsorption 

·         Anaemia

·         Weight loss

Warning sign: Severe anaemia, Generalized oedema, Malabsorption

Complication:

·         Small-bowel obstruction, sometimes complicated by perforation, intussusception, or volvulus. 

·         Biliary colic, cholecystitis, cholangitis,  pancreatitis when large worm can occlude the biliarry tract

Diagnosis:

·         Microscopic examination of feces for eggs or ova of  helminths

·         CBC with PBF—Microcytic  hypochromic  anaemia with eosinophilia

·         In case of complication:  Plain X-ray abdomen , USG of  whole abdomen and   CXR                                                                                                                                               

Treatment:    Drug of choice: ( Any one can be used)

Levamisole, 120 – 150 mg (3 – 4 tablets) P.O. to be taken as a single dose

OR

Albendazole, 400 mg P.O. as a single dose, for children:1 – 2 years, 200 mg as a single dose.

OR

Mebendazole, 100 mg P.O.BID for 3 days

·         Mild iron-deficiency anemia -oral iron .

·          Hypoproteinaemia - nutritional support and oral iron replacement .

·         In case of  acute abdomen   --NPO

                                             --Nasogastric suction,

                                             -- IV antibiotics  ( Ciprofloxacin 200 mg BD)

                                             -- IV Nutrition.

                                             -- If no improvement / deterioration of  condition - Referral

N.B: In pregnancy- Drug of choice- Pyrantel pamoate (11 mg/kg once; maximum, 1 g) . Other drug is contraindicated.

Acute Bloody Dysentery

Introduction

This is a clinical diagnosis based on frequent near-liquid diarrhea flecked with blood, mucus or pus.

Causes

• ·         Shigella
• ·         Campylobacter  jejuni
• ·         Escherichia coli
• ·          Non-typhoid Salmonella
• ·         Entamoeba histolytica
• ·         Non-infectious causes- Ulcerative colitis, clostridium deficile associated diarrhoea (CDAD)

Clinical feature

·         Fever, chill

·         Nausea

·         Body aches, fatigue

·         Abdominal pain or cramping, bloating

·         Fecal incontinence

·         Feeling of incomplete emptying

·         Urgent need to pass stool

·         Vomiting

o    Life threatening feature

·         Confusion and disorientation

·         Difficulty breathing

·         High fever (higher than 101° F)

·         Rapid pulse /  Hypotension

·         Rigid, board-like abdomen

·         Severe abdominal pain

Complication

             Anemia
Dehydration
Hemolytic uremic syndrome or other type of kidney failure
Severe blood loss
Shock

Investigations

·         Stool R/M/E

o    Polymorphoneuclear leucocytosis

o    Trophozoites or cysts of E. histolytica

·         Stool C/S

·         CBC

o    Neutrophilic leucocytosis

·         Blood urea

·         Serum electrolytes

Management

·         General management

o    Rehydration- ORS, if severely dehydrated or vomiting- IV fluid

o    Anti pyretic if required

o    Anti spasmodic if required

o    Don’t use loperamide as this may develop toxic mega colon

·         Specific management

o    Ciprofloxacin 500 mg bid for 3-5 days

o    Metronidazol 400 mg tds for 5 days in case of amoebic dysentery

·         Re-evaluate after 48 hours, if following features appear then refer the patient

o    No improvement

o    Deterioration of patient

Development of complication