Management of cirrhosis Dr Nowlan Selvapatt Consultant Hepatologist Imperial College Healthcare NHS Trust

Overview Understanding the scale of the problem Brief overview of referral pathways Diagnostics in Primary Care Complications of cirrhosis Considerations for Primary Care Management

Understanding the scale of the problem

Increasing Burden of Disease Lancet commission report 2015

Increasing Burden of Disease Lancet commission report 2015

NCEPOD 2013 6 month review of 2454 patient notes Median age of death 56 in females and 58 in males 112/204 had guidelines for management of patients with ALD The initial management plan was unclear or inappropriate in one in six (61/363)

NCEPOD – delivery of care

Referral Pathways

Urgency of referrals Incidental radiological finding with compensated disease VS Decompensated cirrhosis or acute deterioation

Why bother referring?

Diagnostics in primary care

The role of the liver

Understanding components of LFTs AST/ALT Albumin Prothrombin time (bilirubin) Alkaline Phosphatase (GGT) (bilirubin) Platelets

Non invasive predictors Adler, Gulbis, Moreno et al. Hepatology 2019

When to suspect cirrhosis - NICE High risk groups: Malaise, fatigue, anorexia, nausea, weight loss, muscle wasting, or abdominal pain If examination identifies Palpable left lobe of liver, organomegaly Chronic stigmata of CLD Features of decompensated disease including abnormal bruising

When to suspect cirrhosis – NICE (2) If person has chronic liver disease Low platelets Raised AST:ALT ratio Hyperbilirubinaemia Hypoalbuminaemia Raised INR

Complications of cirrhosis

Complications of cirrhosis Varices Ascites Encephalopathy Sepsis Sarcopenia/Nutrition/Frailty Extra hepatic organ dysfunction (kidney, heart, adrenal….)

Sepsis in cirrhosis Bacterial infections in cirrhosis: Frequency leading cause morbidity/mortality in cirrhosis (x4 MR) Frequency hospitalised cirrhotic patients - 32-34% hospitalised cirrhotic patients with GI bleeding - 45% vs. hospitalised patients overall 5-7% 30-50% infections remain “culture negative” in cirrhosis SIRS in cirrhosis is atypical *Bajaj et al; Hepatology ’12 ‘14; Verbake et al; Crit Care ‘11; Moreau et al, Gastro ‘13

Pathophysiological Changes Seen in frailty Laube et al. Liver Int 2018

Frailty, Sarcopenia and Malnutrition

MDT Approach to frailty Management approaches to frailty Exercise Aerobic exercise Resistance training Prehabilitation program prior to surgery or liver transplantation Nutrition Adequate caloric intake to meet daily requirements Protein supplementation Late night snacks

MDT Approach to frailty (2) Pharmacological Consider testosterone supplementation in patients with low serum testosterone levels Cognitive Cognitive training programs including memory, attention and problem‐solving tasks

Primary Care Management

Managing cirrhosis in Primary Care Education Healthy eating and Diet Alcohol consumption and smoking Driving Using Medication Safely Referral to specialty hepatology services

Education https://www.britishlivertrust.org.uk/wp-content/uploads/44952-Cirrhosis-DL-booklet-Web-compressed.pdf

Diet https://www.britishlivertrust.org.uk/wp-content/uploads/44951-DLD-BLT-A5-Booklet-web-compressed.pdf

Prescribing

Take home Identifying cirrhosis can be difficult, diagnosis is often delayed.  Almost half of people with cirrhosis experience no symptoms of liver disease Liver function tests may be normal or only mildly abnormal Some people may present with the less specific features of liver disease, for example, fatigue, itch, or loss of appetite

Take Home (2) Management of cirrhosis is multisystem – refer to specialist hepatology services early Primary care has an important role within the MDT Think: Education Nutrition Medications DVLA