2. Cirrhoses And Its Complications Ahmad Shavakhi

4. The patient A 42 y/o man presented to clinic complaining of malaise and weakness He was well until 2 months ago when weakness developed Phx was unremarkable On no medication

5. Ph.Exam Gynecomastia Minimal ascites spelenomegaly Palmar erythema Spider angioma Clubbing Others were normal

9. LAB DATA AST =80 ALT =60 PT =15 PTT =52 Bil.D :2.1 Bil.T :3.2 CBC : WBC:5600 Hb :12 (MCV=84) PLT :68000 Na=125

10. Sonographic finding u Small shrinkage liver u Large spleen u ascites

11. EGD VARICIES :GRADE 1 Portal hypertensive gasteropathy

13. What is your diagnosis ?

14. Is there any indication for liver Bx in this patient ?

15. u Liver biopsy is not necessary if the clinical, laboratory, and radiologic data strongly suggest the presence of cirrhosis

16. u What is the cause of cirrhosis ?

17. u Alcoholic liver disease u Nash u Hepatitis B and C u Hemochromatosis u AIH u Wilson u A1AT u PBC and PSC

18. LAB DATA VIRAL MARKERS :NEG AUTOIMMUNE MARKERS :NEG Alpha 1 antitrypsin :NL Fe,TIBC,FERRITIN :NL

19. LAB DATA Ascites fluid : SAAG :2.1 WBC :52 (60% LYMPHOCYTE,40% PMN) CULTURE :NEG

20. u What is the severity of cirrhosis ?

21. MELD score u MELD = 3.8[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.6[Ln serum creatinine (mg/dL)] + 6.4

22. CHILD-PUGH SCORING SYSTEM

23. 123 Ascites bil.T mg/dl Alb g/l PT* INR Encephalopat hy Absent <2 >3.5 <1.7 none Slight 2-3 2.8-3.5 1.8-2.3 grade1-2 Moderate >3 <2.8 >2.3 grade3-4 *: Second over control 1 2 3

25. What is your dietary advice to this patient ?

26. Free use Fresh and home-cooked fruit and vegetables Meat/poultry/fish(100g/day) and one egg, one egg=50g meat Unsalted butter,cooking oils,rice Lemon juice,onion,garlic,pepper, Fresh fruit juice Salt free bread Coffee,tea

27. Restrict Milk(300ml) Bread(two slices/day)

28. omit Anything containig baking powder and baking soda(biscuits,cakes) Commercially prepared food Tinned /bottled vegetables Tinned meats/fish Cheese

29. Protein restriction ?

30. What is the program of cancer screening in this patient?

31. Screening for hepatocellular carcinoma periodic( every 6 months) ultrasound examination blood tests?

32. u After few months we found two mass in liver

33. What is the next step u Biopsy u MRI u CT u Observation

35. Does the patient need for vaccination ?

36. Vaccination Patients with cirrhosis are typically vaccinated against : hepatitis A and B Pneumococcal vaccine standard immunizations Haemophilus influenzae and meningococcal :who require a splenectomy e suggest not routinely obtaining antibody titers after immunization. Exceptions for hepatitis B vaccinehepatitis B vaccine healthcare workers, chronic hemodialysis gay or bisexual men spouses of carriers

37. Patient has headache ? What is your advise as pain killer ?

38. u NSAID u Acetaminophen u Mixed drug u COX2 inhibitors

39. Opioids u Morphine :twofold increase in the interval u Meperidine :dose in patients with cirrhosis should be decreased initially by 50 percent u Tramadol and fentanyl :safe

40. What is your idea about the exercise?

41. Exercise generally safe for patients with cirrhosis that is not in an advanced stage. may increase the risk of variceal bleeding in advanced disease (such as those who have ascites or varices).

42. Screen for encephalopathy

43. When do you want to perform the next EGD for follow up?

44. EVERY 2 Y NO VARICES EVERY 1 Y SMALL

45. What does the patient do for prevention of variceal bleeding ?

46. : Patient with small varices (grade 1) : Prophylaxis is not recommended

47. Prophylaxis from variceal bleeding Not Tolerate Medium &large varices Band ligation No contraindication for Beta -blocker Contraindication For Beta -blocker Tolerate Start Beta blocker

48. THE END