Chronic liver disease

Chronic liver disease

Feb 2, 2015 0
gastroenterology & hepatology,onthepods

James talks to Dr Anastasia Volovets about chronic liver disease and common cases on the wards.

Script Writer:  David Ong

Summary Writer:  David Ong

Editor:  James Edwards

Interviewee:  Anastasia Volovets

About Dr Anastasia Volovets

Dr Anastasia Volovets graduated from the University of New South Wales, and completed her junior training at Liverpool Hospital. She completed her Basic Physician Training at the Prince of Wales Hospital and is a second-year Gastroenterology Advanced Trainee at Royal Prince Alfred Hospital.

Chronic liver disease

With Dr Anastasia Volovets, Gastroenterology Advanced Trainee at Royal Prince Alfred Hospital, New South Wales, Australia

Case 1

Confusion on a background of Chronic Liver Disease (CLD)

  • Observations including GCS, and the trajectory of the observations
  • Clarify what is meant by confusion
  • The patient’s context (for example, alcoholic withdrawal becomes an issue 3-5 days into admission)
  • Slow speech, drowsy
  • Rare to have psychotic features
  • Hepatic flap present
  • May be constipated
  • Non compliance with meds such as lactulose
  • Sepsis – Spontaneous bacterial peritonitis, pneumonia, UTI
  • New meds – benzodiazepines, analgesics
  • Treat with Lactulose. If constipated, hrly or 2 hrly lactulose until 5 motions on the first day, and then qid to achieve 3 motions a day. Rifaximin if inadequate response to Lactulose. NG tube if Lactulose not tolerated.
  • Septic screen and commencement of Ceftriaxone; or, inpatients at risk of resistance, consider Tazocin
  • Medication review
  • Diagnostic tap
  • Ammonia level – not so much for JMOs, but as part of a broader workup
  • CTB may be low yield, but is important if there is an acute drop in level of consciousness, focal neurology or seizures

Case 2

Ascites

  • Decompensated liver disease with portal hypertension is unlikely in the absence of splenomegaly, low platelets, low albumin, or high INR.
  • Differentials include:
    • Alcoholic cardiomyopathy
    • Vasculitis and Nephrotic Syndrome
    • Malignancy and omental deposits
  • Diagnostic tap including biochemistry (protein and albumin), cytology, microscopy, culture and sensitivity; Tuberculosis PCR and AFBs if the patient comes from a high risk area. Diagnostic tap is the important investigation in the workup of ascites. The differentials will depend on whether the ascitic fluid is exudate or transudate.  The serum:ascites albumin gradient can help determine the cause.
  • Ultrasound, checking parenchyma and portal flow
  • Echo (especially with a raised JVP)
  • Urine albumin:creatinine
  • Diuretics, starting with 50mg daily Spironolactone adjusted up by 50mg every 48 hours up to 200mg bd, then add frusemide. Treatment should be titrated with daily weights, aiming for a loss of a kg a day at most.
  • Albumin to help with the diuresis – 2  bottles a day
  • A sodium down to 125 is acceptable; if lower then fluid restrict
  • Salt restriction
  • If diuretic refractory, large volume taps are necessary. A bottle of Albumin should be given for every 2L drained
  • Large volume paracentesis can be performed without platelets or FFP if platelets are >20 and INR <3. The relationship between INR and coagulopathy is unclear as these patients can be in fact prothrombotic. Platelets and INR should be corrected for high-risk procedures.
  • Patients with Chronic Liver Disease can be sicker than you think. The prognosis is poor for those with decompensated liver disease. If planning surgery or chemotherapy, get gastroenterology involved earlier.
  • Be careful with medications, such as paracetamol or psychoactive medications, or even innocuous ones such as ondansetron.
  • Nutrition is important – start a high energy high protein low salt diet and contact the dietician

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Tags: #albumin,#ascites,#Ceftriaxone,#Chronic liver disease,#CLD,#confusion,#decompensated liver disease,#diuretics,#gastroenterology,#GCS,#hepatic encephalopathy,#hepatic flap,#Hepatology,#Lactulose,#liver,#Rifaximin,#sepsis,#Tazocin

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