Chronic Liver Disease
10/2/11
Tek OH
Oxford Handbook of Critical Care
OHOA page 134
JFICIM and FANZCA Examinations Book – pages 178-180
- may come to ICU for many reasons:
(1)
(2)
(3)
(4)
(5)
encephalopathy from acute decompensation
sepsis
renal failure
variceal bleeding
cardiorespiratory failure
ENCEPHALOPATHY FROM ACUTE DECOMPENSATION
- find cause:
->
->
->
->
->
->
->
->
sepsis (spontaneous bacterial peritonitis)
dehydration
alcohol
drug introduction (opiates, sedatives, diuretics)
GI haemorrhage
electrolyte imbalances
hepatocellular carcinoma
portal vein thrombosis
HISTORY
-
weakness & fatigue
jaundice
abdominal pain or swelling
altered mental state
pruritis
-
durations of disease
alcohol intake
IV drug use
blood transfusions
tattoos
overseas travel
drugs (isoniazid)
EXAMINATION
-
general – abdominal distension, jaundice, cachexia, bruises
palmar erythema
bruising
spider naevi
yellow sclerae
Jeremy Fernando (2011)
- fetor
- gynaecomastia
-
abdomen: masses, distension, bruising, scars
hepatosplenomegally
ascites
bruits
INVESTIGATIONS
-
FBC – anaemia
U+E – hepatorenal syndrome
BSL
LFT’s – active damage
Albumin – synthetic function
Coags – bleeding
ABG – lactate acidaemia
alpha-feto protein
paracentesis: culture and cell count (>250/mm3 = diagnositic for SBP)
endoscopy – varices
US: hepatic and portal veins, hepatocellular carcinoma
CT: hepatocelluar carcinomia
liver biopsy
MANAGEMENT
-
resuscitate: intubation to protect airway
albumin IV
lactulose to decrease ammonia levels
monitor glucose
vitamin K and FFP for coagulopathy
MARS therapy
feed enterally and can use protein
- find cause and treat:
-> antibiotics in SBP: third generation cephalosporin or tazocin + spinrolactone
-> steroids in alcoholic hepatitis
-> consider for transplantation
SURGICAL RISK (Child-Pugh Classification)
Mortality
< 5%
5-50%
>50%
Bilirubin (mmol/L)
Albumin (g/L)
Ascites
Nutrition
INR
Encephalopathy
<25
>35
none
excellent
<1.7
grade 0
25-40
30-35
moderate
good
1.7-2.3
1-2
>40
<30
marked
poor
>2.3
3-4
Jeremy Fernando (2011)
COMPLICATIONS
Sepsis
- immunosuppressed
- SBP: gram negative rods, strep pneumoniae, enterococci
- other organisms: Listeria, Tb, Fungi, CMV, norcardia
-> early source control
-> early antibiotics (empiric)
Renal Failure
- hepatorenal syndrome -> more likely to see rapidly progressive form
- also consider abdominal compartment syndrome
- investigation: U/S: renal and hepatic
-> volume expansion with colloid (albumin)
-> vasoconstriction (noradrenaline or glypressin)
-> ascitic drainage with albumin loading
-> consider TIPs procedure in Budd-Chari syndrome
-> consider transplantation
Variceal Haemorrhage
- decreased production of factors, thrombocytopaenia, platelet dysfunction)
-> resuscitate
-> correct coagulopathy
-> sepsis of precipitant: culture and give antibiotics
-> splanchic vasoconstriction: glypressin
-> endoscopy: banding and ligation
-> TIPS procedure
-> transplantation
Encephalopathy
- causes: sedation, high protein diet, infection, trauma, hypokalaemia, constipation ->
accumulation of toxic products
- grade 0 = alert and orientated, grade IV = unresponsive to deep pain
Others
-
hypoglycaemia (decreased glycogen stores)
ascites (from portal hypertension and fluid retention)
cholecystitis
pancreastitis
Jeremy Fernando (2011)