END STAGE LIVER DISEASE

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END STAGE LIVER DISEASE
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Discourse

• What is end stage liver disease (ESLD)?
• - Manifestation of ESLD
• - Lab and radiologic investigations
• - Complications of ESLD
• What are the predictors of mortality in ESLD?
• Treatment of Alcoholic liver disease.

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What is ESLD?

• ESLD is usually manifested as cirrhosis of
  the liver, which is a progressive fibronodular
  hyperplasia and bridging fibrosis that results in
  marginal synthetic hepatocellular function,
  cholestasis and variable degree of portal
  hypertension.

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Epidemiology

• ESLD accounted for over 25,000 deaths and 373,000
  hospital discharges in the United States in 1998.
  (The National Center for Health Statistics.)
• It is responsible for about 2 of all death in
  the United States and may account for as much as
  1 of all health care spending

Clin Liver Dis 9 (2005) 103-134.
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Causes of ESLD

• They are myriad, but the most common causes
  include
• Alcohol abuse
• Viral infection
• Autoimmune disease
• Drug reaction
• Genetic metabolic aberrations
• Cholestasis
• Inflammatory disease of the bile tracts.

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Manifestation of ESLD

• Spider telangiectasias
• Palmar erythema
• Nail changes
• Dupuytren's contracture
• Gynecomastia
• Testicular atrophy
• Hepatomegaly

• Splenomegaly
• Ascites
• Caput medusae
• Cruveilhier-Baumgarten murmur
• Fetor hepaticus
• Jaundice
• Asterixis

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Signs of ESLD
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Constitutional Symptoms

• Weakness
• Fatigue
• Anorexia and Weight Loss.
• Other general features that may be seen include
• Low grade fever
• Pigment gallstones
• Parotid gland enlargement
• Diabetes mellitus

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Laboratory findings

• Aminotransferases -AST ALT
• Alkaline phosphatase
• Gamma-glutamyl transpeptidase (GGT)
• Bilirubin
• Albumin

• Globulins
• Serum sodium
• Hematologic abnormalities
• - Anemia
• -Thrombocytopenia
• -Leukopenia
• -Neutropenia
• -Coagulation defects
• (PT INR)

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 Radiography

• Ultrasonography
• "Stiffness" measurement (Fibroscan EchoSens)
• Computed tomography (CT- Scan)
• Magnetic resonance imaging (MRI)
• Nuclear studies

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Confirmative Diagnosis

• The gold standard for diagnosis of cirrhosis is
  liver biopsy, the sensitivity of a liver biopsy
  for cirrhosis ranges from 80 to 100 depending
  on the method used, the size and number of
  specimens obtained.  

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Complications of ESLD

• Malnutrition
• Encephalopathy
• Coagulopathy
• Portal Hypertension
• Variceal Hemorrhage

• Pulmonary Hypertension Hepatopulmonary syndrome
• Hepatorenal Syndrome HRS
• Spontaneous Bacterial Peritonitis SBP
• Hyponatremia

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Prognostic predictors in ESLD

• Patients with ESLD can be stratified into
  different categories of risk based on hepatic
  synthetic reserve.
• Some of the predicting models used in ESLD are -
• Child's classification.
• The Maddrey score
• The model for end stage liver disease score (MELD
  score).

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Childs Classification

• On multivariate analysis, the Child-Pugh
  classification was the best predictor of surgical
  mortality and morbidity .
• Class A cirrhosis - 10 mortality for elective
  surgery. (no particular restrictions)
• Class B cirrhosis - 30 mortality. (tolerate
  elective surgery avoid major hepatic resections)
• Class C cirrhosis - 75 mortality. (with
  abdominal surgery).

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The Maddery score

• Derived in clinical trials of patients with AH
  and used to stratify the severity of illness for
  the use of steroids in AH.
• With hepatic encephalopathy, DF score gt32 is
  correlated with gt50 short-term mortality rate in
  AH.

Gut 2005541174-1179
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The MELD score

• The "model for end stage liver disease score"
  (MELD score) is a statistical model predicting
  survival in patients with cirrhosis.
• There is a good correlation between the Childs
  classification and the MELD scores in predicting
  mortality, especially with emergency surgery.
• The MELD score and the DF have similar
  sensitivities, although the MELD score has a
  higher specificity in predicting outcome in ESLD
• In a report, A MELD score of 8 was useful for
  predicting morbidity after cholecystectomy.

Gut 2005541174-1179
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The use of steroids in AH

• Only patients with severe disease ( hepatic
  encephalopathy and/or DF gt32) should be treated
  with corticosteroids.
• Despite the fact that treatment reduces the
  mortality risk by 25, there is still a 45
  mortality in patients receiving corticosteroids.
• About seven patients need to be treated to avoid
  one death. Careful patient selection is important
  to avoid the side effects of steroids in the
  patients who will derive no clinical benefit from
  them.
• Based on pharmacologic considerations,
  prednisolone (40 mg/d for 4 weeks then tapered
  over 24 weeks) should be used in favor of
  prednisone

Clin Liver Dis 9 (2005) 103-134
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The use of steroids in ESLD

• Most of the reports excluded patients who had
  active GI bleeding, infection, renal failure, or
  pancreatitis. Thus, the efficacy of
  corticosteroids patients with these
  characteristics has not been well studied.
• In the evaluation of patients in whom
  corticosteroids are being considered for
  nonalcohol related liver disease (viral
  hepatitis), It is unclear what impact these
  infections would have on treatment outcome.
• Careful monitoring for evidence of infection,
  gastrointestinal bleeding, glucose intolerance,
  or renal failure is essential while the patient
  is on prednisolone therapy.
• In the patient who responds well and improves
  enough to merit hospital discharge, therapy is
  continued for the complete course, with at least
  weekly outpatient visits

Clin Liver Dis 9 (2005) 103-134
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Effect of steroids in the management of severe AH
Clin Liver Dis 9 (2005) 103-134.
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References

• Alessandra Puggioni, MD Linda L Wong, MD, FACS
  A metaanalysis of laparoscopic cholecystectomy in
  patients with cirrhosis.Journal of the American
  College of Surgeons. Volume197.Number6.December
  2003.
• Thomas W.Faust, MD K. Rajender Reddy, MD
  Postoperative jaundice. Clinics in Liver Disease.
  Volume 8. Number1. February 2004.
• Ricahrd A. Wiklund, MD Preoperative preparation
  of patients with advanced liver disease. Critical
  Care Medicine. Volume 32. Number 4. April 2004.
• Sipriya Balasubramanian, MD Kris V. Kowdley, MD
  Effect of Alcohol on Viral Hepatitis and other
  Forme of Liver Dysfunction. Clinics in Liver
  Disease. Volume 9. Number 1. February 2005.

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References (contd)

• E H Forrest, C D Evans, S Stewart, M Phillips, Y
  H Oo, N C McAvoy, N C Fisher, S Singhal, A Brind,
  G Haydon, J OGrady, C P Hayes, L S Murray, and A
  J Morris Analysis of factors predictive of
  mortality in alcoholic hepatitis and deprivation
  and validation of the Glasgow alcoholic hepatitis
  score. Gut 2005541174-1179 doi10.1136/gut.2004
  .050781.
• Robert S. OShea, MD, MSCE Arthur J. McCullough,
  MD Treatment of Alcoholic Hepatitis. Clin Liver
  Dis 9 (2005) 103-134.
• Chinnasamy Palanivelu, MS. Mch, MNAMS, FACS,
  FRCS Pidigu Seshiyer Rajan, MS, FACS, FICS
  Kaplesh Jani, MS, DNB, MNAMS Alangar Roshan
  Shetty, MS, FICS Karuppasamy Sendhilkumar, MS,
  FACS, FICS Palanisamy Senthilnathan, MS
  Ramakrishnan Parthasarthi, MBBS Laparoscopic
  Cholecystectomy in Cirrhotic Patients the Role
  of Subtotal Cholecystectomy and its Variants.
  Journal of the American College of Surgeons.
  Volume 203. Number 2. August 2006.

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Thank you!
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Questions ?