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
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC