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.