End of Life Care in Liver Disease Dr Allister Grant Consultant Hepatologist Leicester Liver Unit East Leicestershire and Rutland CCG PLT 3rd Sept.

Slides:



Advertisements
Similar presentations
Learning objectives To understand the pathophysiologic basis for vasoactive therapies for HRS To become familiar with the diagnostic criteria for HRS To.
Advertisements

Acute Liver Failure.
Management of ascites in cirrhosis
Operating on patient with Hepatitis C Sonal Asthana, MD and Norman Kneteman, MD Can J Surg August; 52(4): 337–342. Canadian Journal of Surgery The.
CIRRHOSIS. Use of nonspecific has been studied extensively in randomized, controlled trials of the primary prophylaxis of variceal bleeding. β-adrenergic.
 Brian Torski, DO, Internal Medicine PGY-1.  Overview of Hepatorenal Syndrome o Pathophysiology o Diagnosis o Classification o Prevention and Treatment.
Dr Allister J Grant Consultant Hepatologist University Hospitals Leicester NHS Trust.
Chronic Liver Disease Simon Lynes. Definition Progressive destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis.
Risё Stribling, MD Medical Director of Liver Transplant St Luke’s Medical Center Associate Professor of Surgery Baylor College of Medicine.
Teaching Liver cirrhosis with varices. Discussion  Approximately half of patients with cirrhosis have esophageal varices  One-third of all patients.
MAZEN HASSANAIN PORTAL HYPERTENSION. CAUSES Cirrhosis Non-cirrhosis.
Hepatitis web study H EPATITIS C C URRICULUM Terry D. Box, MD Associate Professor of Medicine Division of Gastroenterology/Hepatology University of Utah.
Management of ascites in patients with cirrhosis Treviso 4 Giugno 2009 P. Angeli Dept. of Clinical and Experimental Medicine University of Padova.
Interventional Oncology Michael Kotton MD October 27, 2012.
Lucy Adkinson.  Case history  Reminder of different causes  Update on recent NICE guidance.
For final year medical students 2014 Dr Rosalind Pool GPST1
Treatment of chronic liver disease. Treatment Cause ( Etiology) Cause ( Etiology) Complication Complication.
Complications of Liver Cirrhosis Ayman Abdo MD, AmBIM, FRCPC.
The hepatorenal syndrome. Assessing kidney function in pts with cirrhosis  Cr assays are subject to interference by chromogens, bilirubin being the major.
Liver pathology: CIRRHOSIS
- Definition: - Causes: 1.Liver cirrhosis (Com.). 2.Extra hepatic portal v. occlusion. 3.Intra hepatic veno occlusive Dis. 4.Occlusion of hepatic vein.
Cirrhosis of Liver: Continuation Nursing 2015 Part two 22 to 42slides.
NYU Medical Grand Rounds Clinical Vignette Jeffrey Mayne, MD Third Year Resident Internal Medicine 1/17/2012 U NITED S TATES D EPARTMENT OF V ETERANS A.
CIRRHOSIS OF LIVER PORTAL HYPERTENSION HEPATIC ENCHEPALOPATHY
IV CURSO PARA RESIDENTES DE LA AEEH DIAGNÓSTICO Y TRATAMIENTO DE LAS ENFERMEDADES HEPÁTICAS Barcelona, de Octubre de 2013 ASCITIS Y SINDROME HEPATORRENAL.
HEPATORENAL SYNDROME – LIVER PERSPECTIVE Dr. S. Shivakumar M.D., Addl. Professor of Medicine, Govt.Stanley Medical College, Chennai – By.
0 Hepato-renal Syndrome – What is it? Akash Deep, Director - PICU King’s College Hospital London.
HEPATO renal Syndrome Type I: Correct Diagnosis = Correct Management Stephen G. M. Wong BSc, BSc(Med), MD, MHSc, FRCPC Associate Professor of Medicine.
HEPATOCELLULAR CARCINOMA Monton. HCC in Thailand Most common cancer in Thai male Incidence 5 x 100,000 / year Male : female = 3-8:1 Age > 40 yr.
Hepatorenal Syndrome Dr Allister J Grant Leicester Liver Unit
This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration.
Creatinine (mg/dL) MonthsWeeks Therapeutic paracentesis Cefotaxime Type-2 HRSType-1 HRS Encephalopathy Jaundice CLINICAL TYPES.
CASE PRESENTATION DR NADIA SHAFIQUE. CASE SUMMARY  38 yrs old female GULSHAN diagnosed case of HCV related DCLD (child class C) CTP score 11presented.
Portal Hypertension portal venous pressure > 5 mmHg
+ Liver Transplantation for PSC Patients A Transplant Surgeon’s Perspective Tiffany Anthony, MD Annette C. and Harold C. Simmons Transplant Institute Baylor.
Principles of anesthesia in cirrhotic patients
The patient with alcoholic liver disease in ITU Dr Mark Hudson Liver Unit, Freeman hospital Newcastle upon Tyne.
Cirrhosis 18 November 2009 Thomas C Sodeman MD Associate Professor of Medicine Chief, Division of Gastroenterology.
Spontaneous Bacterial Peritonitis Katherine Yu May 2014.
Assist. Prof. Mona Arafa Tropical Medicine Department
Questions to be answered
C IRRHOSIS. A LCOHOLIC L IVER I NJURY : Alcoholic Liver disease - Patterns Fatty change, Acute hepatitis Chronic hepatitis Cirrhosis, Chronic Liver failure.
Complications of liver cirrhosis
Acute On Chronic Liver Failure- Evolution of Concept 23 October 2015.
Complications of liver cirrhosis
Hepatocellular carcinoma related to Hbv and Hcv
Complications of Liver Cirrhosis
Management of patients with cirrhosis and refractory ascites Treviso 4 Giugno 2009 P. Angeli Dept. of Clinical and Experimental Medicine University of.
Journal Club Leona Isabella von Köckritz.
Ascites 소화기내과 F1 김경엽.  Ascites: pathologic accumulation of fluid in the peritoneal cavity Causes of ascitesPercentage Cirrhosis81 % Cancer10 % Heart.
Definition  Is a chronic disease characterized by scaring and necrotic tissue replaced by fibrotic tissue. Resulting in hepatic insufficiency and portal.
Chronic liver disease Multiple causes, common manifestation.
Complications of liver cirrhosis. Recognize the major complications of cirrhosis. Understand the pathological mechanisms underlying the occurrence of.
INTERNAL MEDICINE BENJAMIN YIP 4/13/16 Mini Lecture: Hepatorenal Syndrome.
CIRRHOSIS MANAGEMENT FOR HOSPITALISTS Madhav Devani 6/7/16.
Intern Report Patient Presentation  55yM no PMH presenting with worsening abdominal pain for 2-3 days. Describes pain as diffuse, non-radiation,
Managing the Cirrhotic Patient
Acute Upper GIT bleeding
Liver Disease tutoring Part 2
GASTROENTEROLOGY 2009;137:892–901 R2. 정 회 훈.
Dip. Software based statistics-
Managing Complications of Cirrhosis
Spontaneous Bacterial Peritonitis
Multiple factors can predispose to decompensation in a patient with cirrhosis. Risk factors for decompensation include: Bleeding Infection Alcohol.
COMPLICATIONS OF CIRRHOSIS
Care of Patients with Liver Problems
Vandana Khungar, Sammy Saab  Clinical Gastroenterology and Hepatology 
Internal medicine L-4 Liver cirrhosis & portal hypertension
Presentation transcript:

End of Life Care in Liver Disease Dr Allister Grant Consultant Hepatologist Leicester Liver Unit East Leicestershire and Rutland CCG PLT 3rd Sept

Death rates for liver disease

Facts  Liver disease is the 5th largest cause of death in the U.K.  The average age of death from liver disease is 59 years, compared to years for heart & lung disease  UK is one of few developed nations with an upward trend in mortality.

Expanded Portal Tracts (Blue)

Prognosis- Child Pugh Score Score Encephalopathy 0 I/II III/IV Ascites Absent Mild-moderate Severe Bilirubin (µmol/l) 51 Albumin (g/l) >3528– –35 <28 INR 1.5 Child-Pugh classA  6 B = 7–9 C  10

Prognosis 1 Year Survival – Child Pugh A % – Child Pugh B % – Child Pugh C %

Complications of End Stage Liver Disease  Decompensated Cirrhosis Variceal bleeding Variceal bleeding Ascites Ascites Encephalopathy Encephalopathy  Other Sepsis (SBP) Sepsis (SBP) Hepatorenal syndrome Hepatorenal syndrome Hepatocellular carcinoma Hepatocellular carcinoma

Disease Progression Liver function 100% Cirrhosis Liver Failure Transplant Death Years A B C

Disease Progression Liver function 50% Cirrhosis Liver Failure Transplant Death Months

Portal Circulation

Oesophageal varices

Management of Bleeding Varices  Prevention  Resuscitation  Endoscopy -Band Ligation Sclerotherapy  Pharmacotherapy- Terlipressin  Balloon Tamponade  TIPS/Transplantation

Oesophageal varices

Bleeding Gastric Varices

Variceal Bander

Variceal Band Ligation

Variceal Bleeding in Palliative Care  May be occult and present as encephalopathy - Gastric -Duodenal-Colonic  Resuscitate if appropriate  Correct coagulopathy  Give Terlipressin if known varices As effective as balloon tamponade As effective as balloon tamponade As effective as endoscopic therapy As effective as endoscopic therapy  ?Give PPI/ sucralfate / tranexamic acid  Colonic varices- rectal balloon tamponade

Ascites

Causes of Ascites 20% of patients with ascites have a non hepatic cause 5% of patients with hepatic ascites have a second cause Peritoneal disease- carcinomatosis, TB Heart failure Diabetic nephropathy Hypoalbuminaemia of other causes

The Development of Ascites Peripheral arterial dilatation Reduced effective blood volume Hypoalbuminaemia Activation of renin-angiotensin-aldosterone system Sympathetic nervous system ADH Na retention & Water retention Low urinary Na Dilutional hyponatraemia Ascites Schrier et al Hepatol Plasma volume expansion NaCl Ascites and Oedema

General Management Hepatic Ascites and Oedema  Salt restriction  Diuretics spironolactonefrusemide  Water restriction if sodium < 125 mmol  Paracentesis diagnostic (SBP, tumour) therapeutic (Total vs partial + colloids)  Daily weight

Sampling of Ascites  Coagulopathy is not a contraindication to diagnostic paracentesis (unless clinically evident fibrinolysis or DIC)  FFP/platelets are not required  In uncomplicated hepatic ascites request cell count and [Albumin] PMN>250 cells/mm 3 indicates SBP transudate/exudate 25g/L serum/ascites albumin gradient >11g/L= Portal Hyp Runyon et al Ann Int Med 1992

Spontaneous Bacterial Peritonitis Definition- “SBP is a bacterial infection of ascitic fluid which arises in the absence of any other source of sepsis within the peritoneum or adjacent tissues” PMN>250 cells/mm 3 Mortality rate similar to that of a variceal bleed (20-40%)

Secondary prevention of SBP  Patients who survive SBP have a 1y recurrence rate of 40-70%  Norfloxacin 400mg/day reduces recurrence from 68% to 20%  Locally we use Septrin 960mg od Mon-Fri  Median survival of these patients is 9mo  These patients should be considered for liver transplantation/ GSF

Sepsis in Cirrhosis  Incidence- 1% of all admissions to hospital are due to sepsis 30-50% of cirrhotic patients admitted to hospital due to sepsis Once admitted 15-35% of cirrhotics develop infection (c.f. 5-7% general hospital population)

General Management Encephalopathy Treat precipitants Sepsis Sepsis GI bleed GI bleed Medications (over-diuresis) Medications (over-diuresis) Stop sedatives, hypnotics, opiatesStop sedatives, hypnotics, opiates ConstipationConstipation Lactulose (NG/PR/PO) Metronidazole/ Rifaximin/ neomycin -deafness

Acute Kidney Injury in CLD  Exclude urinary infection  Exclude obstructive uropathy  Trial of volume  Avoid nephrotoxins NSAIDs NSAIDs IV contrast IV contrast  Avoid over-diuresis  Avoid hypotension  Hepatorenal Failure carries grave prognosis

Hepatorenal Syndrome  Hepatorenal Syndrome is a severe complication of end stage liver disease associated with an 80%-95% mortality at 2 weeks.  The only interventions that have been shown to improve survival are liver transplantation, the vasopressin analogues and TIPS  Type 1 (Acute)  Type 2 (Chronic)

HRS Survival Gines et al Lancet 2003

The Development of HRS Reduced effective blood volume Activation of renin-angiotensin-aldosterone system Sympathetic nervous system ADH Na retention & Water retention Low urinary Na Dilutional hyponatraemia Ascites Schrier et al Hepatol Plasma volume expansion Renal vasoconstriction Reduced GFR NSAID Aminoglycosides Diuretics Sepsis NaCl Ascites and Oedema HRS Increases Terlipressin Splanchnic vasoconstriction ↓ ↓↓ X Peripheral arterial dilatation ↑ Renal Perfusion Albumin

Hepatocellular Carcinoma  All UK cirrhotic patients undergo 6 monthly HCC surveillance with USS and AFP  AFP >400 is diagnostic of HCC  Focal lesion – MRI/triple phase CT Arterialised nodule, washout in venous phase Arterialised nodule, washout in venous phase

Surveillance in Cirrhosis  Surveillance for Hepatoma 6 monthly AFP and USS

Pruritis After exclusion of other causes of Itching consider  Biliary Obstruction  PBC in the absence of Jaundice  Cholestasis/Jaundice  Drugs

Pruritis  Biliary Obstruction Stones Stones Stricture Stricture 1  or 2  Tumour 1  or 2  Tumour Nodes Nodes

MRCP

ERCP

ERCP

Drugs for Pruritis  Non-Specific Management Lubricants/Topical agents Lubricants/Topical agents Reduce irritation Reduce irritation Prevent scratching Prevent scratching Systemic Anti-pruritics Systemic Anti-pruritics AtaraxAtarax Fexofenidine etcFexofenidine etc  Liver Disease Cholestyramine Cholestyramine Ursodeoxycholic acid Ursodeoxycholic acid Rifampicin Rifampicin Opioid antagonists, naloxone, naltrexone Opioid antagonists, naloxone, naltrexone Ondansetron Ondansetron

Other Treatments Ultraviolet light exposure Ultraviolet light exposure Plasmapheresis Plasmapheresis Liver Transplantation Liver Transplantation

Future  Liver disease is an important cause of mortality in the U.K. In 2000 it killed more men than Parkinson’s disease and more women than cancer of the cervix.  ~1% of population HCV positive  Mortality from Alcoholic liver disease doubled in 10 years  Incidence of liver cancer has doubled in 10 years  4% of the population have abnormal liver function  50% people with colorectal cancer develop liver metastases, 20% resectable

The End “All right, let's not panic. I'll make the money by selling one of my livers. I can get by with one “ Doh!