1. Complications of Liver Cirrhosis Ayman Abdo MD, AmBIM, FRCPC

2. Objectives 1. Understand the basic mechanisms of portal hypertension 2. Recognized the classic presentations of portal hypertension complications 3. Get an idea on the management of these complications

3. What is Liver Cirrhosis? Diffuse fibrosis of the liver with nodule formation Abnormal response of the liver to any chronic injury

4. Causes of Cirrhosis 1. Chronic viral hepatitis 2. Metabolic: hemochromatosis, Wilson dis, alfa-1-antitrypsin, NASH 3. Prolonged cholestasis (primary biliary cirrhosis, primary sclerosing cholangitis) 4. Autoimmune diseases (autoimmune hepatitis) 5. Drugs and toxins 6. Alcohol

5. Anatomy of the portal venous system

6. The Effect of The Liver Nodule

7. Mechanism of Portal HTN Cirrhosis Resistance portal flow Mechanical Nodules Dynamic Nitric oxide

8. Complications of Portal Hypertension

9. 1. Varices

10. Collaterals

11. Varices EsophagusGastricColo-rectal Portal hypertensive gastropathy

13. Varices Diagnosis History : Hematemases, melena Physical examination Ultrasound abdomen Endoscopy

14. Varices Management-General ABC 2 IV Lines Type and cross match Resuscitation IVF IVF Blood Blood Platelet transfusion (platelet <75,000) Fresh frozen plasma (Correct Pt)

15. Varices Management-Specific IV vasoconstrictors (Octreotide) Endoscopic therapy BandingSclerotherapyShuntingSurgicalTIPS

16. Variceal Banding

17. Types of Shunts TIPS (Transjugular intrahepatic portosystemic shunt) Surgical shunt

18. Varices Prevention Treat underlying disease Endoscopic banding protocol B-blockers Shunt surgery (only if no cirrhosis) Liver transplantation

19. 2. Ascites

20. Ascites Definition: fluid in the peritonial cavity

21. Mechanism of Ascites

22. Causes of Ascites 1. Liver disease: cirrhosis 2. Right sided heart failure 3. Kidney disease (nephrotic syndrome) 4. Low albumin (malnutrition, bowel loss) 5. Peritonial infection (TB…) 6. Peritonial cancer

23. Presentation History: Increased abdominal girth Increased wt Physical exam: Bulging flanks Shifting dullness Fluid wave

24. Diagnosis Physical examination Ultrasound Ascitic tap WBC (>250 PMN: SBP) RBC SAAG (serum albumin to ascitic fluid albumin gradient) >11 mg/dl : portal hypertension <11 mg/dl : Other

25. Portal hypertension or heart failure Peritonial disease or kidney disease

26. Treatment-General Treat the underlying disease Salt restriction (<2gm/d) Diuretics Loop diuretic (Lasix) Aldosterone inhibitor (Spironolactone )

27. Treatment-Resistant Recurrent tapping Peritoneal-venous shunt TIPS Liver transplantation

28. Spontaneous Bacterial Peritonitis Infection of ascitic fluid Usually gram negative (E.Coli) Presentation variable Mortality is high Dx: ascitic tap = PMN>250 Treatment : third generation cephalosporin IV

29. 3. Hepatic Encephalopathy

30. Hepatic Encephalopathy Reversible decrease in neurological function secondary to liver disease Acute: seen with acute liver failure Acute on chronic: established cirrhosis

31. Hepatic Encephalopathy Mechanism

32. Hepatic Encephalopathy Clinical features Reversal of sleep pattern Disturbed consciousness Personality changes Intellectual deterioration Fetor hepaticus AstrexisFluctuating

33. Flapping Tremor

35. Drawing Tests

36. Hepatic Encephalopathy Diagnosis Clinical (most important) The drawing tests EEG CT/MRI may show cerebral atrophy

37. Hepatic Encephalopathy Exacerbating factors

38. Hepatic Encephalopathy Treatment Identify and treat precipitation factor Treat underlying liver disease Normal protein diet Antibiotics (Neomycin, metronidazole) LactoloseTransplantation

39. 4. Hepatorenal Syndrome

40. Hepatorenal Syndrome Progressive renal failure Type 1 : rapidly progressive, high mortality Type 2: slower progression R/O volume depletion secondary to diuretics IV vasoconstrictors Liver transplantation

41. Summary 1. Mechanical compression of blood flow plus hemodynamic changes leads to portal hypertension 2. Common complications of portal hypertension are: Collateral formation (Varices) Collateral formation (Varices) Ascites Ascites Hepatic encephalopathy Hepatic encephalopathy

42. Summary 3. The most important step in variceal bleed management is resuscitation 4. The most important step in management of hepatic encephalopathy is the identification of the precipitating factor