2. Cirrhoses And Its Complications Ahmad Shavakhi.MD Associate professor of gastroenterology

4. The patient u A 42 y/o man presented to clinic complaining of malaise and weakness u He was well until 2 months ago when weakness developed u On no medication

5. Ph.Exam Gynecomastia Minimal ascites spelenomegaly Palmar erythema Spider angioma Clubbing Others were normal

9. LAB DATA AST =80 ALT =60 PT =15 PTT =52 Bil.D :2.1 Bil.T :3.2 CBC : WBC:5600 Hb :12 (MCV=84) PLT :68000 Na=125

10. Sonographic finding u Small shrinkage liver u Large spleen u ascites

11. What is your diagnosis ?

12. Is there any indication for liver Bx in this patient ?

13. u Liver biopsy is not necessary if the clinical, laboratory, and radiologic data strongly suggest the presence of cirrhosis

14. What is the cause of cirrhosis ?

15. What is the importance ? Alcoholic liver disease Nash Hepatitis B and C Hemochromatosis AIH Wilson A1AT PBC and PSC

16. LAB DATA VIRAL MARKERS :NEG AUTOIMMUNE MARKERS :NEG Alpha 1 antitrypsin :NL Fe,TIBC,FERRITIN :NL

17. LAB DATA Ascites fluid : SAAG :2.1 WBC :52 (60% LYMPHOCYTE,40% PMN) CULTURE :NEG

18. u Doppler sonography : normal

19. u What is the severity of cirrhosis ?

20. MELD score u MELD = 3.8[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.6[Ln serum creatinine (mg/dL)] + 6.4

21. CHILD-PUGH SCORING SYSTEM

22. 123 Ascites bil.T mg/dl Alb g/l PT* INR Encephalopat hy Absent <2 >3.5 <1.7 none Slight 2-3 2.8-3.5 1.8-2.3 grade1-2 Moderate >3 <2.8 >2.3 grade3-4 *: Second over control 1 2 3

24. What is your dietary advice to this patient ?

25. Free use Fresh and home-cooked fruit and vegetables Meat/poultry/fish(100g/day) and one egg, one egg=50g meat Unsalted butter,cooking oils,rice Lemon juice,onion,garlic,pepper, Fresh fruit juice Salt free bread Coffee,tea

26. Restrict Milk(300ml) Bread(two slices/day)

27. omit Anything containig baking powder and baking soda(biscuits,cakes) Commercially prepared food Tinned /bottled vegetables Tinned meats/fish Cheese

28. Protein restriction ?

29. What is the program of cancer screening in this patient?

30. Screening for hepatocellular carcinoma Periodic( every 6 months) ultrasound examination blood tests

31. Does the patient need for vaccination ?

32. Vaccination Patients with cirrhosis are typically vaccinated against : hepatitis A and B Pneumococcal vaccine standard immunizations Haemophilus influenzae and meningococcal :who require a splenectomy not routinely obtaining antibody titers after immunization. Exceptions for hepatitis B vaccinehepatitis B vaccine healthcare workers, chronic hemodialysis gay or bisexual men spouses of carriers

33. Patient has headache ? What is your advise as pain killer ?

34. u NSAID u Acetaminophen u Mixed drug u COX2 inhibitors

35. Opioids u Morphine :twofold increase in the interval u Meperidine :dose in patients with cirrhosis should be decreased initially by 50 percent u Tramadol and fentanyl :safe

36. What is your idea about the exercise?

37. Exercise generally safe for patients with cirrhosis that is not in an advanced stage. may increase the risk of variceal bleeding in advanced disease (such as those who have ascites or varices).

38. Screen for encephalopathy

39. When do you want to perform the next EGD for follow up?

40. EGD VARICIES :GRADE 1 Portal hypertensive gasteropathy

42. EVERY 2 Y NO VARICES EVERY 1 Y SMALL

43. What does the patient do for prevention of variceal bleeding ?

44. : Patient with small varices (grade 1) : Prophylaxis is not recommended

45. Prophylaxis from variceal bleeding Not Tolerate Medium &large varices Band ligation No contraindication for Beta -blocker Contraindication For Beta -blocker Tolerate Start Beta blocker

46. Home massage u After diagnosis of cirrhosis : u Etiology u Severity u Sonography ( ordinary and doppler ) u EGD u Vaccination

47. THE END