Dr Allister J Grant

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Dr Allister J Grant Consultant Hepatologist Univer
sity Hospitals Leicester NHS Trust
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Anatomy Physiology
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Anatomy Physiology
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Anatomy Physiology
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Anatomy Physiology
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Liver Functions

• Nutrition/Metabolic
• stores glycogen (glucose chains)
• releases glucose when if no insulin
• absorbs fats, fat soluble vitamins
• manufactures cholesterol
• Bile Salts
• lipids derived from cholesterol
• dissolves dietary fats (detergent)
• Bilirubin
• breakdown product of haemoglobin

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Liver Functions

• Clotting Factors
• manufactures most clotting factors
• Immune function
• Kupfer cells engulf antigens (bacteria)
• Detoxification
• drug excretion (sometimes activation)
• alcohol breakdown
• Manufactures Proteins
• albumin
• binding proteins

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Symptoms

• Early disease
• asymptomatic
• fatigue, malaise
• anorexia, nausea
• jaundice
• pruritis
• easy bruising and bleeding
• abdominal pain

• Cholestatic patients
• fatigue, malaise
• anorexia, nausea
• jaundice
• pruritis
• grey or clay-coloured stools

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Disease Progression

• Acute Liver Failure
• lt6 weeks duration
• Jaundice
• Encephalopathy
• Cerebral Oedema
• Acute Renal Failure
• Acidosis
• Hypoglycaemia
• MOF

• Chronic Liver Disease
• gt6 months
• Cirrhosis leading to
• Recurrent decompensation
• Ascites
• Portal Hypertension (variceal bleeding)
• Encephalopathy
• Low albumin/Malnutrition
• Hepatorenal syndrome
• Hyponatraemia
• Hepatoma

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Disease Progression
100
A
B
Liver function
Cirrhosis
Liver Failure
C
Years
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Causes of Chronic Liver disease

• Viral
• Hepatitis B
• Hepatitis C
• Autoimmune Hepatitis
• Metabolic
• NASH
• Amyloid
• Alcoholic Cirrhosis

• Inherited
• Haemochromatosis
• Wilsons Disease
• ?-1 Antitrypsin Deficiency
• Biliary Disease
• PBC
• PSC
• Secondary sclerosing cholangitis
• Carolis syndrome

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Signs of Chronic Liver Disease

• None
• Asterixis/Flap
• Relative hypotension
• Oedema
• Jaundice/No jaundice
• Large/Small liver
• Splenomegaly
• Gynecomastia
• Testicular atrophy-loss of secondary sexual
  characteristics

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Cirrhosis
Expanded Portal Tracts (Blue)
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Decompensation in Cirrhosis

• Means the development of-
• Ascites
• Hepatic Encephalopathy
• Portal hypertension (variceal haemorrhage)

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Decompensation in Cirrhosis

• Means the development of-
• Ascites
• Hepatic Encephalopathy
• Portal hypertension (variceal haemorrhage)

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The Development of Ascites
50 of compensated cirrhotics develop ascites
over 10yrs 50 of cirrhotics with ascites will
die within 2 yrs (50 2yr rule for OLTx
assessment)
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The Development of Ascites
Peripheral arterial dilatation
Reduced effective blood volume
Activation of renin-angiotensin-aldosterone
system Sympathetic nervous system ADH
Na retention Water retention
Ascites and Oedema
Low urinary Na Dilutional hyponatraemia
Plasma volume expansion
Ascites
Schrier et al Hepatol 1988
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Decompensation in Cirrhosis

• Means the development of-
• Ascites
• Hepatic Encephalopathy
• Portal hypertension (variceal haemorrhage)

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Encephalopathy

• Grade 1
• Constructional apraxia
• Poor memory number connection test
• Agitation/ irritability
• Reversed sleep pattern
• Grade 2
• Lethargy, disorientation
• Asterixis
• Grade 3
• Drowsy, reduced conscious level
• Grade 4
• Coma

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Causes of Encephalopathy

• INCREASED AMMONIAGENESIS
• Increased substrate (protein) for ammoniagenesis
• Increased protein intake
• Gastrointestinal bleeding
• Constipation
• Dehydration
• Increased substrate (urea) for ammoniagenesis
• Renal failure
• Increased catabolism of protein
• Infection
• Hypokalemia
• Sepsis

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Causes of Encephalopathy

• DECREASED HEPATOCELLULAR FUNCTION
• Worsened intrinsic liver disease
• Hypoxia
• Anaemia
• Development of hepatocellular carcinoma
• Dehydration
• Hypotension
• Sepsis
• Drug toxicity
• Superimposed viral hepatitis

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Causes of Encephalopathy

• INCREASED PORTOCAVAL SHUNTING
• Portal vein thrombosis
• Transjugular intrahepatic portosystemic shunt
  formation
• Surgical shunt formation
• Spontaneous shunt formation
• PSYCHOACTIVE DRUG USE
• Benzodiazepines
• Ethanol
• Antiemetics
• Antihistamines
• Others

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Decompensation in Cirrhosis

• Means the development of-
• Ascites
• Hepatic Encephalopathy
• Portal hypertension (variceal haemorrhage)

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Portal Circulation
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Oesophageal varices
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Prognosis

• 1 Year Survival
• Child Pugh A 80 - 100
• Child Pugh B 60 - 80
• Child Pugh C 35 - 45

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Management of Bleeding Varices

• Prevention
• Resuscitation
• Endoscopy - Band Ligation Sclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS

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Management of Bleeding Varices

• Prevention
• Resuscitation
• Endoscopy - Band Ligation Sclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS

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Fluid Management

• Crystalloid
• Colloid
• Blood
• Platelets
• FFP
• Vitamin K

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Management of Bleeding Varices

• Prevention
• Resuscitation
• Endoscopy - Band Ligation Sclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS

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Oesophageal varices
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Oesophageal varices
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Bleeding Gastric Varices
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Variceal Bander
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Variceal Band Ligation
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Management of Bleeding Varices

• Resuscitation
• Endoscopy - Band Ligation Sclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS

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PharmacotherapyTerlipressin vs. Balloon
TamponadeMortality
Favours Terlipressin
Favours Tamponade
Terlipressin vs. Endoscopic TherapyMortality
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Management of Bleeding Varices

• Resuscitation
• Endoscopy - Band Ligation Sclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS

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Sengstaken-Blakemore Tube
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Complication of SBT
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Management of Bleeding Varices

• Resuscitation
• Endoscopy - Band Ligation Sclerotherapy
• Pharmacotherapy- Terlipressin
• Balloon Tamponade
• TIPS

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The End
All right, let's not panic. I'll make the money
by selling one of my livers. I can get by with
one
Doh!