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.