Chronic Liver Disease

OVERVIEW

• may come to ICU for many reasons:

(1) encephalopathy from acute decompensation
(2) sepsis
(3) renal failure
(4) variceal bleeding
(5) cardiorespiratory failure

ENCEPHALOPATHY FROM ACUTE DECOMPENSATION

Find cause:

• sepsis
• spontaneous bacterial peritonitis
• GI haemorrhage
• alcohol
• drugs (opiates, sedatives, diuretics)
• electrolyte imbalances
• hepatocellular carcinoma
• portal vein thrombosis
• dehydration

HISTORY

• weakness & fatigue
• jaundice
• abdominal pain or swelling
• altered mental state
• pruritis

• durations of disease
• alcohol intake
• IV drug use
• blood transfusions
• tattoos
• overseas travel
• drugs (isoniazid)

EXAMINATION

• general – abdominal distension, jaundice, cachexia, bruises
• palmar erythema
• bruising
• spider naevi
• yellow sclerae
• fetor
• gynaecomastia

• abdomen: masses, distension, bruising, scars
• hepatosplenomegaly
• ascites
• bruits

INVESTIGATIONS

• FBC – anaemia
• U+E – hepatorenal syndrome
• BSL
• LFTs – active damage
• Albumin – synthetic function
• Coag – bleeding
• ABG – lactate acidaemia
• alpha-feto protein
• paracentesis: culture and cell count (>250/mm3 = diagnostic for SBP)
• endoscopy – varices
• US: hepatic and portal veins, hepatocellular carcinoma
• CT: hepatocellular carcinoma
• liver biopsy

MANAGEMENT

• resuscitate: intubation to protect airway
• albumin IV
• lactulose to decrease ammonia levels
• monitor glucose
• vitamin K and FFP for coagulopathy
• MARS therapy
• feed enterally and can use protein
• find cause and treat:
  -> antibiotics in SBP: third generation cephalosporin or tazocin + spironolactone
  -> steroids in alcoholic hepatitis
  -> consider for transplantation

SURGICAL RISK – Child-Pugh Classification (see liver failure definitions)

	A	B	C
Mortality	< 5%	5-50%	50%
Bilirubin (mmol/L)	<25	25-40	40
Albumin (g/L)	>35	30-35	<30
Ascites	none	moderate	marked
Nutrition	excellent	good	poor
INR	<1.7	1.7-2.3	>2.3
Encephalopathy	grade 0	grade 1-2	grade 3-4

COMPLICATIONS

Sepsis

• immunosuppressed
• SBP: gram negative rods, strep pneumoniae, enterococci
• other organisms: Listeria, Tb, Fungi, CMV, norcardia
  -> early source control
  -> early antibiotics (empiric)

Renal Failure

• hepatorenal syndrome -> more likely to see rapidly progressive form
• also consider abdominal compartment syndrome
• investigation: U/S: renal and hepatic
  -> volume expansion with colloid (albumin)
  -> vasoconstriction (noradrenaline or glypressin)
  -> ascitic drainage with albumin loading
  -> consider TIPs procedure in Budd-Chiari syndrome
  -> consider transplantation

Variceal Haemorrhage

• decreased production of factors, thrombocytopaenia, platelet dysfunction)
  -> resuscitate
  -> correct coagulopathy
  -> sepsis of precipitant: culture and give antibiotics
  -> splanchnic vasoconstriction: glypressin
  -> endoscopy: banding and ligation
  -> TIPS procedure
  -> transplantation

Encephalopathy

• causes: sedation, high protein diet, infection, trauma, hypokalaemia, constipation -> accumulation of toxic products
• grade 0 = alert and orientated, grade IV = unresponsive to deep pain

Others

• hypoglycaemia (decreased glycogen stores)
• ascites (from portal hypertension and fluid retention)
• cholecystitis
• pancreatitis