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LIVER CIRRHOSIS IN PSC: DIAGNOSIS AND MANAGEMENT

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Presentation on theme: "LIVER CIRRHOSIS IN PSC: DIAGNOSIS AND MANAGEMENT"— Presentation transcript:

1 LIVER CIRRHOSIS IN PSC: DIAGNOSIS AND MANAGEMENT
Douglas A Simonetto, M.D. Assistant Professor of Medicine Mayo Clinic, Rochester, MN test

2 THE NORMAL LIVER OFFERS ALMOST NO RESISTANCE TO FLOW
Hepatic vein Liver Portal vein

3 Distorted architecture
ARCHITECTURAL LIVER DISRUPTION IS THE MAIN MECHANISM THAT LEADS TO AN INCREASED INTRAHEPATIC RESISTANCE Cirrhotic Liver Varices Distorted architecture Portal Hypertension Enlarged spleen

4 NATURAL HISTORY Chronic Liver Disease ? years Compensated Cirrhosis
Portal Hypertension ~ 10 years Decompensated Cirrhosis Complications Of Liver Disease ~ 2-5 years Liver Transplantation

5 DIAGNOSIS OF CIRRHOSIS
Liver Biopsy

6 DIAGNOSIS OF CIRRHOSIS
Transient Elastography (FibroScan)

7 DIAGNOSIS OF CIRRHOSIS
Magnetic Resonance Elastography (MRE)

8 COMPLICATIONS OF CIRRHOSIS
Varicose veins in the esophagus (esophageal varices) Fluid in the abdomen = Ascites Confusion = Encephalopathy

9 VARICOSE VEINS IN THE ESOPHAGUS

10 VARICOSE VEINS IN THE ESOPHAGUS
1/3 bleeding large varices without prophylaxis No varices Small varices Large varices

11 PREVENTION OF VARICEAL BLEEDING
Nonselective Beta-Blockers Nadolol Propranolol Carvedilol Band Ligation 1/3 bleeding large varices without prophylaxis

12 PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis MANAGEMENT ALGORITHM FOR THE PROPHYLAXIS OF VARICEAL HEMORRHAGE

13 PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy MANAGEMENT ALGORITHM FOR THE PROPHYLAXIS OF VARICEAL HEMORRHAGE

14 PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy No Varices Follow-up EGD in 2-3 years MANAGEMENT ALGORITHM FOR THE PROPHYLAXIS OF VARICEAL HEMORRHAGE

15 PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy No Varices Small Varices Follow-up EGD in 1-2 years Follow-up EGD in 2-3 years MANAGEMENT ALGORITHM FOR THE PROPHYLAXIS OF VARICEAL HEMORRHAGE

16 PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy Large Varices Beta-blocker therapy No Varices Small Varices Follow-up EGD in 1-2 years Follow-up EGD in 2-3 years MANAGEMENT ALGORITHM FOR THE PROPHYLAXIS OF VARICEAL HEMORRHAGE

17 PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy Large Varices Beta-blocker therapy No Varices Small Varices Follow-up EGD in 1-2 years Follow-up EGD in 2-3 years MANAGEMENT ALGORITHM FOR THE PROPHYLAXIS OF VARICEAL HEMORRHAGE Stepwise increase until maximally tolerated dose Continue beta-blocker indefinitely No need for repeat/serial EGD No Contraindications

18 PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy No Varices Small Varices Follow-up EGD in 1-2 years Large Varices Follow-up EGD in 2-3 years MANAGEMENT ALGORITHM FOR THE PROPHYLAXIS OF VARICEAL HEMORRHAGE Beta-blocker therapy Endoscopic Variceal Band Ligation No Contraindications Stepwise increase until maximally tolerated dose Continue beta-blocker indefinitely No need for repeat/serial EGD Contraindications or Beta-blocker intolerance

19 ASCITES (FLUID IN THE ABDOMEN)
Most common complication of cirrhosis Symptoms: Distention/bloating Decreased appetite Shortness of breath

20 ASCITES (FLUID IN THE ABDOMEN)
Step 1: Sodium Restriction 2,000 mg of sodium per day Step 2: Combination Diuretics Furosemide and Spironolactone 30% risk in 5 years

21 ASCITES (FLUID IN THE ABDOMEN)
Step 3: Large Volume Paracentesis Safe to repeat as needed Bleeding risk <0.3% Intravenous albumin sometimes needed Step 4: TIPS 30% risk in 5 years

22 Transjugular Intrahepatic Portosystemic Shunt (TIPS)
30% risk in 5 years

23 CONFUSION (ENCEPHALOPATHY)
Brain dysfunction caused by toxins (including ammonia) Wide spectrum of symptoms Mood changes, sleep issues to disorientation, drowsiness and slurred speech Risk of first episode of HE is 5-25% within 5 years after cirrhosis diagnosis

24 Failure to filter/metabolizetoxins
Encephalopathy CONFUSION (ENCEPHALOPATHY) Toxins Step 3: Large Volume Paracentesis Safe to repeat as needed Bleeding risk <0.3% Intravenous albumin sometimes needed Step 4: TIPS Toxins Shunting Failure to filter/metabolizetoxins Risk of first episode of HE is 5-25% within 5 years after cirrhosis diagnosis Waste products

25 CONFUSION (ENCEPHALOPATHY)
Treatment: Lactulose Laxative – 3-5 bowel movements Rifaximin Antibiotic – Taken twice a day

26 SUMMARY Diagnosis Ascites (fluid in the abdomen) FibroScan
MRE Liver Biopsy Labs/Imaging Ascites (fluid in the abdomen) Sodium restriction Diuretics Paracentesis TIPS Varicose veins in the esophagus Endoscopy Nadolol, propranolol, carvedilol Band ligation Encephalopathy (confusion) Lactulose Rifaximin

27 test

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