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

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

3. Understanding the scale of the problem

4. Increasing Burden of Disease
Lancet commission report 2015

5. Increasing Burden of Disease
Lancet commission report 2015

6. 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)

7. NCEPOD – delivery of care

8. Referral Pathways

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

12. Why bother referring?

13. Diagnostics in primary care

14. The role of the liver

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

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

17. 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

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

19. Complications of cirrhosis

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

21. Sepsis in cirrhosis Bacterial infections in cirrhosis: Frequency
leading cause morbidity/mortality in cirrhosis (x4 MR)
Frequency
hospitalised cirrhotic patients %
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

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

23. Frailty, Sarcopenia and Malnutrition

24. 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

25. 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

26. Primary Care Management

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

28. Education

29. Diet

30. Prescribing

32. 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

33. 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