Presentation is loading. Please wait.

Presentation is loading. Please wait.

Cirrhosis and complications Cengiz Pata Gastroenterology Department Yeditepe University.

Similar presentations


Presentation on theme: "Cirrhosis and complications Cengiz Pata Gastroenterology Department Yeditepe University."— Presentation transcript:

1 Cirrhosis and complications Cengiz Pata Gastroenterology Department Yeditepe University

2 Overview 1) Criteria for Referral for Transplantation 2) Varices 3) Ascites/TIPS 4) S.B.P. 5) Encephalopathy 6) Hepatorenal Syndrome 7) Hepatocellular Carcinoma

3 Etiology Enfections (HBV, HCV, HDV, HGV) Hereditary disease (Wilson, Hemokromatozis, Alfa-1 antitripsin,tyrosinemia) Toksic (alchol,drugs(Mtx) İmmünologic (OİH) Vasculer (corpulmonare, Budd Chiarry, Portal ven trombosis) Bilier Disease (PBS, Cystic Fibrosis,Sarcoidosis,PSK,PFIK,SBS) Malnutrision, Bypass surgery İndian Child Age Disease NAFLD

4 Reasons for Liver Transplantation: U.S. Etiology % Disease from Hepatitis C 40 IDU 65%, BT 5%, others Alcohol 30 alcoholism PBC/PSC 10 congenital Hemochr <5 genetic HBV 5 vertical/horizontal Biliary atresia 30 congenital Metabolic d/o 20 congenital

5 Fibrosis Progression: Hepatitis C Slide courtesy of Bennett, MD. CirrhosisSevere Fibrosis Normal LiverMild fibrosis

6 CIRRHOTIC LIVER

7

8 How do we know if a patient has cirrhosis/ portal hypertension ? Liver biopsy: Stage IV scarring CT scan: hypertrophied L lobe, nodular contour, enlarged portal vein, splenomegaly, varices, ascites Labs: low platelet count, elevated bilirubin, prolonged INR Physical exam: spider angiomata, jaundice, splenomegaly, ascites, leg edema

9 Timing of referral for consideration of liver transplant ? 1 point 2 points 3 points Albumin (g/l) >3.5 2.8-3.5 <2.8 Ascites None Slight Moderate Bilirubin (mg/dl) <2 2-3 >3 Encephalopathy None Mild-Mod Severe Prothrombin/INR 1-4 s/1.7 4-6 s/1.7-2.2 >6 s/>2.2 A: 5-6, B: 7-9, C: 10 or more Modification for Bilirubin in PBC/PSC: 1-4, 4-10, >10

10 Timing of referral for consideration of liver transplant ? Since February 2002, listing for transplantation is on the basis of a MELD score and a CPT score MELD (Model for End-Stage Liver Disease): developed at Mayo Clinic as a separate “liver disease severity index” MELD: 0.38xlog e (bilirubin, mg/dl) + 1.12xlog e (INR) + 0.96 xlog e (creatinine, mg/dl) + 0.64x etiology Website: www.unos.org

11 Implication for Transplant Many of complications of cirrhosis were formerly considered reasons to “increase a patient’s status,” specifically: 1) Refractory variceal bleeding 2) Refractory hepatorenal syndrome 3) Refractory hepatic encephalopathy -were accepted as reasons to make patients on the list for transplant “2A,” and give them higher priority

12 Variceal Bleed Monitor Liver Function PT, Alb, Bili q 3-6 months Hepatoma Surveillance U/S, AFP q 6 months Varices Surveillance Compensated Decompensated Encephalopathy Treatment Recommendations- Cirrhosis Figure 1. Treatment Flow Sheet for Patients with Cirrhosis SBP Ascites Hepatorenal Synd. (Garcia-Tsao G, 2003) Vaccination- in HCV, against HAV, HBV

13 Variability in Natural History of Cirrhosis Natural history is clearly variable based on: - ongoing alcohol consumption, leading to acute exacerbations in portal pressures, particularly increasing risk for variceal hemorrhage - relation between cirrhosis etiology and HCC (HBV>HCV>?NASH)

14 Morbidity and Mortality in Compensated Cirrhosis Type C: A Retrospective Follow- up Study of 384 Patients Fattovich G et al, Gastroenterology 1997;112:463 AscitesEnc/J Mean follow-up: 5 years

15 Morbidity and Mortality in Compensated Cirrhosis Type C: A Retrospective Follow-up Study of 384 Patients 26% of patients decompensated during follow-up (8% HCC, 18% other) Odds of decompensation: 12% at 3 years, 18% at 5 years, 29% at 10 years Probability of survival after decompensation: 50% at 5 years Death: 51 (13%): roughly 1/3 HCC, 1/3 liver failure, 1/3 unrelated to cirrhosis Fattovich G et al, Gastroenterology 1997;112:463

16 Effect of Hepatitis B and C Virus Infections on the Natural History of Compensated Cirrhosis: A Cohort Study of 297 Patients Fattovich G et al, Am J Gastro 2002;97:2886 Median f/u: 6.5 years

17 Effect of Hepatitis B and C Virus Infections on the Natural History of Compensated Cirrhosis: A Cohort Study of 297 Patients HCV: 53% decompensated (17% HCC, 36% other) HBV: 34% decompensated (14% HCC, 20% other) Probability of 5-year survival after decompensation: HBV 28%, HCV 47% Death or liver transplant: 70 (22% of HBV, 26% of HCV) Fattovich G et al, Am J Gastro 2002;97:2886

18 Gines, Hepatology 1987. PROBABILITY OF DEVELOPING DECOMPENSATED CIRRHOSIS 257 patients with compensated cirrhosis time in months number being followed

19 Cirrhosis Natural History Studies Summary No decompensation: 80% 10-year survival Decompensation is variable, imperfectly predicted. Portal HTN vs. synthetic dysfunction HCC, ascites: the 2 principal forms of decompensation Risk of decompensation: roughly 4-5% per year in a patient with Child’s A cirrhosis After decompensation, probability of 5-yr survival without transplant: 35-50%

20 Time to disease progression DB treatment and off-treatment follow- up Percentage with disease progression Time to disease progression (months) Placebo (n=215)ITT population Lamivudine (n=436)p=0.001 Lamivudine Placebo P=0.001 21% 9%

21 Risks of Complications of Cirrhosis Cirrhosis Variceal Bleeding HCC Ascites Encephalopathy adapted from Bennett WG et al, Ann Intern Med 1997;127:855 0.4 % 1.5% 2.5 % 1.1% percent per year Death Liver Transplant 11 % ?20+% ?30+%

22 Median Survival Times in Cirrhosis Compensated Cirrhosis9 yrs Decompensated Cirrhosis1.6 yrs –Jaundice –Encephalopathy –Ascites –Variceal hemorrhage SBP9 mos HRS type II6 mos HRS type I2 wks

23 Bleeding Varices

24 Varices-Background Management of acute or acutely-bleeding varices is accepted: a) IV octreotide b) band ligation > sclerotherapy for esophageal varices, TIPS placement (or attempts at glue injection at some sites) for acutely-bleeding gastric varices. 7 days of antibiotics recommended Controversies: 1) Primary prophylaxis 2) Secondary prophylaxis

25 Primary Prophylaxis- Varices 15-25% of unselected cirrhotics screened endoscopically will have large or high-risk varices Mortality of first variceal hemorrhage remains high, 20-35% D’Amico G et al, Hepatology 1995;22:332-54 Fewer studies on prevalence of gastric varices in unselected cirrhotics; 4% ? Sarin S et al, Hepatology 1992;16:1343-49

26 Prevention of FIRST Variceal Hemorrhage Meta-Analysis (11 trials) ControlBeta-blockerAbsolute Rate Difference Bleeding Rate 25%15% -10% (- 16 to –5) Death Rate 27%23%-4% (- 9 to 0) Large Varices 30% (n=411) 14% (n=400) -16% (- 24 to –8) Small Varices 7% (n=100) 2% (n=91) -5% (-11 to 2) D’Amico et al. Sem Liv Dis 1999

27 Prediction of Large Varices Platelet count, Child-Pugh class independent risk factors for the presence of any varices (plts <90K) and large varices (plts <80K) in 300 cirrhotics without prior bleeding being evaluated for OLT Zaman A et al, Arch Int Med 2001;161:2564-70

28 Zaman et al, Arch Int Med 2001 Clinical FeatureNo varices (n=97) Small varices (n=109) Large varices (n=94) Encephalopathy 34%47%54% Platelets (mean) 129,000107,00076,000 Splenomegaly (u/s) 62%61%73% Ascites44%53%63% Platelet count OR 2.3, p=.001 Child-Pugh class OR 2.75, p=.007 Multivariate Predictors of Large Varices:

29 Primary Prophylaxis Beta-blockers reduce the incidence of first variceal hemorrhage compared to placebo Poynard T et al., NEJM 1991;324:1532-1538 Band ligation may be more effective than Propranolol in high risk patients Sarin S et al, NEJM 1999;340:988-93

30 Primary Prophylaxis of Varices: An algorithm It is reasonable to perform endoscopic screening in all cirrhotics (stable, willing to be tx’d); it should likely be performed in all Child’s C cirrhotics  Beta blockade (Propranolol, Nadolol, goal HR 55-60) is the preferred approach; band ligation is an alternative for high risk varices or in patients who can’t tolerate Propranolol - not as many data in gastric varices nor portal gastropathy, but prophylaxis may be similar

31 Secondary Prophylaxis of Varices Variceal hemorrhage has a 2-year recurrence rate of 80% Once acute bleeding has resolved, two large trials have found that beta- blockade and band ligation have similar efficacy in controlling rebleeding Minyana J et al, Hepatology 1999;30:215A Patch D et al, J Hepatology 2000;32:34

32 Secondary Prophylaxis of Varices Banding sessions are typically repeated at 7-14-day intervals until obliteration, typically 2-4 sessions TIPS vs endoscopic tx: rebleeding less with TIPS, but worse encephalopathy, no change in mortality Papatheodoridis GV, Hepatology 1999;30:612-22  Beta-blockers or banding are first-line

33

34 Hepatic encephalopathy GIS bleeding Enfection higher protein diuresis constipation Elektrolit inbalance Dehidratation Sedative Hepatik injury Portasistemic shunt

35

36 Hepatic encephalopathy Liver failure, failure of CNS 1 year survive %40 NH3, Glutamine,katekolamine, serotonine,GABA

37 Stages of Hepatic encephalopathy 0-1 : psychometric tests slow 1: abnormal sleep, dyscordination 2: lethargy, ataxia, disarthria,behavirol dysinhibition, asterix, poor tests 3:confusion, delirium, semi stupor, incontinence, disorientation, amnesia, rigidity, paranoia, abnormal reflex, nistagmus, babinski 4: coma, no cognition, no behavior, decortica or decerebrate, dilated pupils

38 Hepatic encephalopathy Treatment General support Treatment of etiologic factor Medical : Lactulose, antibiotic (neomycin,metronidazole) Flumazenil Transplantation

39 HRS impaired renal function İmpaired arteriel circulation Renal vazoconstruction GFR↓ No pathologic lesion 1 mounths survival %95 %7-15 Type 1:weeks, agrrevation important ( diuretic, parasenthesis, SBP..) Type 2 : mounths, better prognose

40 Hepatorenal Syndrome 2 types: Type I: rapid development of renal dysfunction (Cr rising to >2.5mg/dl in 2 weeks): median survival 2 weeks Type II: slower rise, Cr >1.5mg/dl  Management: 1) Ensure Diagnosis 2) Liver Transplantation

41 HRS Major Criteria GFR low (cre1.5mg/dl↑ or Cre clirence 40↓) No shock, nefrotocsic drug, enfection or loss of fluid Good function after stoping diuretic and 1,5 lt saline No paranchymal disease or nefrolithiasis on US 500mg/d↓/day proteinuri Minor Criteria Urine volume 500↓ Urine Na 10 mEg/L↓ Higher urine osmolarite than plasma Serum Na 130 mEg/L↓ 50 red cell↓ urine

42 HRS Dopamine Mizoprostole Vazopressine (Orlipressin,terlipressin) TIPS MARS Transplantation

43 Uriz J Hepatol 2000;33:43-18 TERLIPRESSIN+ ALBUMIN IN HRS

44 U Heemann et al. Hepatology 2002; 36: 949-958 EXTRACORPOREAL ALBUMIN DIALYSIS MARS

45 Natural History of Cirrhosis in 2005: Altered by What We Do More aggressive screening, for varices, HCC will mean problems are identified earlier Ablative therapies for HCC Obliteration of varices/ beta- blockade TIPS Liver Transplantation


Download ppt "Cirrhosis and complications Cengiz Pata Gastroenterology Department Yeditepe University."

Similar presentations


Ads by Google