4 What other symptoms would you want to ask about? Case StudyMr C, 35 year old man, presents to his GP with mild abdominal pain and yellowing of the whites of his eyes (noticed by his girlfriend who is a nurse).What other symptoms would you want to ask about?
5 Signs and Symptoms of Liver pathology Abdominal pain (RUQ)JaundiceNausea, vomiting Weight lossAbdo distensionHaematemesis and malaenaBreast swelling, tesicular atrophyConfusionSpider naeviPalmar erythemaDupuytrens contractureHepatomegaly, Spenomegaly
6 Case study cont:Has recently has ‘flu’ – has felt generally unwell, tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.What risk factors would you ask about?
7 Risk factors for liver disease High Alcohol intakeBlood-to-blood contact (IVDU, Tattoos, infected transfusions, needlestick injuries)Unprotected sexDrugs (prescribed, OTC, herbal)TravelFamily history of liver disease (autoimmune hepatitis, Wilson’s disease)Mr C is in monogamous sexual relationship with girlfriend for 2 months– she is on OCP. No barrier contraception.Drinks approximately 30 units alcohol / week. Denies any other risk factors.What first line investigations would you like to do?
8 Liver Function Tests Viral hepatitis: Alcoholic hepatitis ALT greatly raised (10-100x upper limit of normal)Alcoholic hepatitisALT moderately raised (2-10x upper limit of normal)Drug induced hepatitisMixed picture: raised hepatic (AST, ALT) and Cholestatic (Alk Phos and GGT) markersAbnormal clotting (prolonged PT or INR) may indicate acute liver failure
9 Drugs commonly associated with Hepatitis Acute hepatocellular damage:Paracetamol (dose related)Alcohol (dose related)TB drugsAnticonvulsantsAzathioprineMethotrexateChronic active hepatitisNitrofurantoinIsoniazideIntrahepatic cholestasisOestrogenserythromycin
10 Other causes: EBV, CMV, paravirus B19, dengue, yellow fever. Hep AHep BHep CHep DHep ERoute of transmissio nFaecal-oral (contaminate d water/food, oro-anal sex)Blood products, body fluids, sexual contactsBlood productsAs for Hep BContaminated waterPeople at riskChildcare workers, MSMvertical transmission, sexual partners, healthcare workers, Tattoos, body piercings, blood transfusions, IVDUIVDU, tattoosLess commonly: vertical transmission, sexual transmissionThose at risk of Hep B or with chronic Hep BTravel to endemic areas, and sporadic outbreaks associated with poor sanitation eg refugee campsPotential for chronic infectionnoneCommon in infants (90%), rarer in adults (10%)80% develop chronic infectionCo-infection with Hep BIncubation period3 weeks (range 2-7)10 weeks(range 4-26)7 weeks(range 2-21)5 weeks(range 3-7)(range 3-8)Other causes: EBV, CMV, paravirus B19, dengue, yellow fever.
19 Cirrhosis: common end point of many disease processes Alcohol excessHepatitis BHepatitis CNon-alcoholic Fatty Liver disease / Non-alcoholic SteatohepatitisHaemachromatosisPrimary Biliary CirrhosisPrimary Scelosis CholangitisAutoimmune hepatitisWilson’s disease and other inherited metabolic disorders
21 How would you investigate decompensated liver disease? Bloods:likely increased biliruben, AST, ALT, alk phos, GGT;Decreased albumin, increased PT/INR (reduced synthetic function);Decreased WCC and platelets (hypersplenism);Look for the cause: serology, autoantibodies, iron studiesImaging: liver US and doppler, MRIAscitic tap:Biopsy: confirm clinical diagnosis
22 US liver“fibrotic, structurally abnormal nodules in liver …. Compatible with cirrhosis. Doppler shows signs of portal hypertension.”
23 Complications of Cirrhosis Anaemia (folate deficiency, hypersplenism)Thrombocytopenia (hypersplenism)Coagulopathy (reduced production of clotting factors) – can lead to DICOesophageal varicesSpontaneous Bacterial PeritonitisHepatic encephalopathyHepatocellular carcinoma
24 How would you manage this patient? Patient education and supportTreat underlying causeAdequate nutrition (calorie and protein intake)Careful prescribingTherapeutic ascetic tapAlcohol abstinence (also important in non- alcohol induced cirrhosis)Alcohol dependent individuals will require: Chlordiazepoxide, Thiamine, Vitamin BMonitoring for further complications:oesophageal varicies or HCC?transplant
25 What other questions would you ask her??? Case Study“A 17 year old girl presents to the GP with a 8 week history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”What other questions would you ask her???
26 She denies......jaundice, dyspepsia, vomiting, malena, constipation, ulcersChanges in appetiteChanges in mensustral cycleurinary symptomsNo recent travelNo changes / alterations to her dietShe reportsFatigue – low energy levelsSOBOEPalpitationsFrequent PyrexiaAbdominal pain – generalised crampsDiarrhoea – no blood or mucusWeight Loss
27 What are you going to do next?? Clinical ExaminationInvestigationsUrine Dip and MSUBloods :FBC, U&E's , CRP, ESR, LFT's, TFT's, Electrolytes, Anti -TTG, Blood Cultures??Stool cultureImaging
28 What is your immediate management plan? ClinicOn examinationTachycardic – 101 regular, good volume.normotensive – 110/76CPT > 3 secPale conjunctiveCardio- respiratory examination - NADDiffuse tenderness in the abdomennormal PRWhat is your immediate management plan?WCC15.9HB8.2MCV89Platelets289ESRHIGHCRP110urea17creatnineK+4.6na+135LFT'sNADTFT'sCulturesNo growth
34 Primary Sclerosing Cholangitis Strongly association with UC (less with CD)Inflammation, fibrosis and stricture of the intra/ extra hepatic ducts.Signs of Live failureLFTS- Raised Alkaline Phosphatase, Bilirubin, hypergamaglobinuminaANA, ANCA, SMA +VEPoor prognosis – often need transplant and increases risk of cholangiocarcinoma
35 Management MEDICAL MANAGEMENT Treatment of exacerbations : Mild – oral steroids (Prednislone PO / PR)Severe – IV Hydrocortisone and AntibioticsMaintenance therapy :Maintain adequate nutritionTo prevent exacerbations5-ASA's (Mesalazine)AzothioprineAnti- TNF antibodies(INFLIXIMAB)Goals of treatment1) to achieve the best possible clinical, laboratory, and histological control of the inflammatory disease with the least adverse effects from medication;(2) to promote growth with adequate nutrition; and(3) to permit the patient to function as normally as possible (eg, in terms of school attendance, participation in activities).
36 Surgical Management Surgical management of complications Surgical management of the condition
37 What else do you want to know??? CASE STUDYA 25 year old girl presents with a 8 week history of generalised abdominal cramps and diarrhoea. They are loose stool, no blood or mucus and can occur 8-10 times a day. She also reports that she is frequently tired and stressed.What else do you want to know???
38 Irritable bowel Syndrome Incidence: common (female ) ; 40 % people attending secondary care6 months of symptoms before diagnosisCan be predominantly constipation or predominantly diahorrea.Abdominal pain/ BloatingAnxiety / depressionIncomplete emptying/ incontinence/ urgencyConstitunal symptoms : tiredness, lethargy, arthalgia, urinary symptoms, dyspurunina.RED FLAG SYMPTOMS:Bleeding, Nocturnal symptoms, weight loss, Age > 50
39 Treatment Options Reassurance and support Address / Treat underlying medical issuesLifestyle advice :Dietary modification – excluding food groups.Smoking and alcoholSymptomatic relief :Bloating – Peppermint oilConstipation – increase fibre and fluid intakeAntispasmodics – mebevrine
40 Case Study“A 65 year old man presents with a 4 day history of black tarry stools. He reports that they are becoming more frequent and loose. He also reports nausea and one episode of vomiting this morning.He also reports that he has a back ache for the past fortnight and has been taking OTC painkillers for it and would like you to prescribe some more”
41 Causes of Upper GI bleeding Common causes:Ulcers – Peptic ulcers (40%)Varices – Secondary to portal hypertension (17%)Gastritis / gastric erosionDuodenitisOesphagitisRarer causes:Mallory -Weiss tearsAngiodysplasiaBleeding DisordersPeutz- Jeugher's SyndromeOsler – Webb – Rendu Syndrome
42 Examination / Investigation On Examination:He is tachycardic, at 111 bpm / regular and borderline hypotensive 105/72.He is tender in the epigastrium and peri-umbilically. There is some voluntary guarding. Bowel sounds are normal.DRE – Malodorous black tarry stool. No fresh blood.Investigations:Bloods : Hb , Urea -21 , Creatnine 66, WCC- 7.0, platelets- 260, CRP – 2.2, LFT's – NAD.AXR – NADErect CXR – No free air under the diapgram
43 Management CALL FOR HELP RE- ASSESS Bleep : RR -30 BP- 90 /66 , HR -122, CRT > 3, Sats – 94%A - No airway compromiseB – O2, ABGC – IV access + Fluid Challenge (which??), Bloods. IV PPI, erect CXR, AXRD – GCS, Pupils , GlucoseE - everything else: check notes,CALL FOR HELPRE- ASSESS
44 Rockall Score Pre-scope score : predicts the morbidity and mortality Post -scope score : predicts the risk of re-bleeding
45 Bleeding secondary to ulcers ABC approachIV PPIEndoscopy: CAUTERISTION or CLIPPING of the ulcerBleeding secondary to variciesThis is a sign of decompensationABC approachIV Terlipressin (+ \ - Propanalol)Clotting abnormality – correct itOctreotide ( often given by seniors)Secondary prevention (propanolol)
46 Management of Variceal Bleeding Sengstaken Blakemore Tube : Balloon DecompressionTIPS : Trans-jugular intrahepatic porto systemic shunt
47 A catheter into the hepatic vein, guidewire was passed into a portal vein branch. The tract was dilated with a balloon, and contrast injected. A metallic stent placed over the wireA catheter into the hepatic vein and after needle puncture, a guidewire was passed into a portal vein branch. The tract was dilated with a balloon, and contrast injected. A self-expandable metallic stent placed over the wireTIPS