Douglas A Simonetto MD Assistant Professor of Medicine Mayo Clinic Rochester MN LIVER CIRRHOSIS IN PSC DIAGNOSIS AND MANAGEMENT Normal Liver Hepatic vein Portal vein Liver THE NORMAL LIVER OFFERS ALMOST NO RESISTANCE TO FLOW ID: 773961
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Douglas A Simonetto, M.D.Assistant Professor of MedicineMayo Clinic, Rochester, MN LIVER CIRRHOSIS IN PSC: DIAGNOSIS AND MANAGEMENT
Normal Liver Hepatic vein Portal vein Liver THE NORMAL LIVER OFFERS ALMOST NO RESISTANCE TO FLOW
Varices Distorted architecture Portal Hypertension Cirrhotic Liver Enlarged spleen ARCHITECTURAL LIVER DISRUPTION IS THE MAIN MECHANISM THAT LEADS TO AN INCREASED INTRAHEPATIC RESISTANCE
Chronic Liver Disease Compensated CirrhosisDecompensated Cirrhosis Liver Transplantation Complications Of Liver DiseasePortal Hypertension ~ 2-5 years~ 10 years? yearsNATURALHISTORY
DIAGNOSIS OF CIRRHOSIS Liver Biopsy
DIAGNOSIS OF CIRRHOSIS Transient Elastography (FibroScan)
DIAGNOSIS OF CIRRHOSIS Magnetic Resonance Elastography( MRE )
COMPLICATIONS OF CIRRHOSIS V aricose veins in the esophagus (esophageal varices) Fluid in the abdomen = Ascites Confusion = Encephalopathy
VARICOSE VEINS IN THE ESOPHAGUS
VARICOSE VEINS IN THE ESOPHAGUS Small varices Large varices No varices
PREVENTION OF VARICEAL BLEEDING Nonselective Beta-Blockers Nadolol Propranolol CarvedilolBand Ligation
Diagnosis of Cirrhosis PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy No Varices Follow-up EGD in 2-3 years PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy No Varices Follow-up EGD in 2-3 years Small VaricesFollow-up EGD in 1-2 years PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy No Varices Follow-up EGD in 2-3 years Small VaricesFollow-up EGD in 1-2 years Large Varices Beta-blocker therapy PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy No Varices Follow-up EGD in 2-3 years Small VaricesFollow-up EGD in 1-2 years No Contraindications Large Varices Beta-blocker therapy Stepwise increase until maximally tolerated dose Continue beta-blocker indefinitely No need for repeat/serial EGD PREVENTION OF VARICEAL BLEEDING
Diagnosis of Cirrhosis Endoscopy No Varices Follow-up EGD in 2-3 years Small VaricesFollow-up EGD in 1-2 years Large Varices Stepwise increase until maximally tolerated dose Continue beta-blocker indefinitely No need for repeat/serial EGD No Contraindications Contraindications or Beta-blocker intolerance Beta-blocker therapy Endoscopic Variceal Band Ligation PREVENTION OF VARICEAL BLEEDING
ASCITES (FLUID IN THE ABDOMEN) Most common complication of cirrhosisSymptoms:Distention/bloatingDecreased appetite Shortness of breath
ASCITES (FLUID IN THE ABDOMEN) Step 1: Sodium Restriction2,000 mg of sodium per dayStep 2: Combination DiureticsFurosemide and Spironolactone
ASCITES (FLUID IN THE ABDOMEN) Step 3 : Large Volume Paracentesis Safe to repeat as neededBleeding risk <0.3%Intravenous albumin sometimes neededStep 4: TIPS
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
CONFUSION (ENCEPHALOPATHY) Brain dysfunction caused by toxins (including ammonia) Wide spectrum of symptoms Mood changes, sleep issues to disorientation, drowsiness and slurred speech
CONFUSION (ENCEPHALOPATHY) Step 3 : Large Volume Paracentesis Safe to repeat as neededBleeding risk <0.3%Intravenous albumin sometimes neededStep 4: TIPS EncephalopathyWaste productsFailure to filter/metabolizetoxinsToxins Shunting Toxins
CONFUSION (ENCEPHALOPATHY) Treatment: Lactulose Laxative – 3-5 bowel movements Rifaximin Antibiotic – Taken twice a day
SUMMARY Diagnosis FibroScan MRE Liver Biopsy Labs/Imaging Ascites (fluid in the abdomen) Sodium restrictionDiureticsParacentesisTIPSVaricose veins in the esophagusEndoscopyNadolol, propranolol, carvedilolBand ligation Encephalopathy (confusion)LactuloseRifaximin