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Home | CCC | Chronic Liver Disease

Chronic Liver Disease

by Dr Chris Nickson, last update April 24, 2019

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)

ABC
Mortality< 5%5-50% 50%
Bilirubin (mmol/L)<2525-40 40
Albumin (g/L)>3530-35<30
Ascitesnonemoderatemarked
Nutritionexcellentgoodpoor
INR<1.71.7-2.3>2.3
Encephalopathygrade 0grade 1-2grade 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

CCC 700 6

Critical Care

Compendium

…more CCC

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About Dr Chris Nickson

An oslerphile emergency physician and intensivist suffering from a bad case of knowledge dipsosis. Key areas of interest include: the ED-ICU interface, toxicology, simulation and the free open-access meducation (FOAM) revolution. @Twitter | INTENSIVE| SMACC

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