Chronic liver disease cld
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Chronic Liver Disease (CLD). Insidious onset Complication of viral infection, eg hepatitis Metabolic, eg alcohol Genetic, eg Haemachromatosis, Wilson’s, Porphyria Tumour Immunological, eg Primary Biliary Cirrhosis Drugs, eg Methotrexate, NSAIDs Obstructive, eg Budd Chiari.

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Chronic Liver Disease (CLD)

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Chronic liver disease cld

Chronic Liver Disease (CLD)

  • Insidious onset

  • Complication of viral infection, eg hepatitis

  • Metabolic, eg alcohol

  • Genetic, eg Haemachromatosis, Wilson’s, Porphyria

  • Tumour

  • Immunological, eg Primary Biliary Cirrhosis

  • Drugs, eg Methotrexate, NSAIDs

  • Obstructive, eg Budd Chiari


Patient presentation

Patient Presentation

  • “Flu” like symptoms (malaise)

  • Jaundice

  • Pruritis

  • Malnutrition

  • Ascites and peripheral oedema

  • Portal hypertension

  • Effect on other functions, eg respiratory, renal, cardiac, immune

  • May have pain

  • Encephalopathy


Portal hypertension

Portal Hypertension

  • Caused by intra-hepatic resistance due to sinusoidal collapse

  • Causing “backflow” into circulatory system (collateral vessels)

  • Measured using invasive monitoring – Central Venous Pressure (CVP)


Major complication oesophageal varices

Major Complication:Oesophageal Varices

  • Engorged vessels in lower oesophagus and around gastric cardia

  • Risk of bleeding – can be severe

  • Haemorrhage can occur at any time in CLD (30-50% of all deaths associated with CLD, especially Alcoholic Liver Disease)


Treatment of oesophageal varices

Treatment of Oesophageal Varices

If haemorrhaging:

  • Replacement of blood volume (colloid, blood)

  • Urgent endoscopy

    • Sclerotherapy

    • Banding

  • Balloon tamponbade – if continued bleeding (Sengstaken tube)

  • Drug therapy

    • Acute, IV Vasopressin

    • Long-term, beta blockers, antacids


Hepatic encephalopathy

Hepatic Encephalopathy

  • Disordered consciousness (confusion)

  • Occurs both in chronic liver failure and acute

  • Various theories on cause

    • Abnormal ammonia metabolism most likely (Ammonia is a by-product of protein metabolism, healthy liver converts ammonia to urea then excreted by kidneys)

  • Encephalopathy classified into four grades


Treatment of hepatic encephalopathy

Treatment of Hepatic Encephalopathy

  • Maintain safe environment

  • Monitor level of consciousness

  • Regular laxative – Lactulose (20–30 mls tds.)

  • Phosphate enemas

    (We no longer restrict protein intake)


Ascites

Ascites

  • Ascites: Marked increase in the volume of fluid in the peritoneal cavity

  • Rarely painful, unless infected,

  • Respiratory complications,

  • Haemodynamic complications  CVP  MAP

  • Renal impairment

  • Reduced mobility and nutrition


Treatment of ascites

Treatment of Ascites

  • Low sodium diet

  • Fluid restriction (1500ml / 24 hours)

  • Diuretic therapy – Spironolactone

  • Abdominal Paracentesis – with IV Albumin replacement


Stigmata of chronic liver disease

Stigmata of Chronic Liver Disease

  • Gynaecomastia

  • Palmar Erythema

  • Dupytrens Contracture

  • Caput Medusae

  • Fetor Hepaticus

  • Jaundice

  • Clubbing

  • Spider Naevi

  • Xanthomata

  • Hair loss

  • Asteriscis (tremor)


Alcohol withdraw

Alcohol Withdraw

  • Can occur after a short but sustained alcohol binge

  • Early intervention will halt progression to delirium tremens (DTs)

  • Signs and symptoms

    • Nervousness

    • Restlessness

    • Tremor (flap)

    • Confusion

    • Nausea and vomiting

    • Patient may hallucinate

    • Risk of seizures


Acute liver disease ald

Acute Liver Disease (ALD)

  • Onset of days or weeks

  • Complication of viral infection, eg hepatitis

  • Drugs, eg Paracetamol, NSAIDs

    • May lead to Fulminant hepatic failure

    • ? Need for transplant


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